Proceedings of the Denver Epidemiology Work Group (DEWG) April 18, 2014. The Denver Office of Drug Strategy The Denver Drug Strategy Commission

Proceedings of the Denver Epidemiology Work Group (DEWG) April 18, 2014 The Denver Office of Drug Strategy The Denver Drug Strategy Commission

Table of Contents Attendees 3 Agenda.4 Purpose and Distribution 5 Executive Summary.6-9 Report on Recent Alcohol and Drug Trends in Denver Metro Area.10-48 Data Sources 49-51 Presentation: The Harm Reduction Action Center 52-58 Presentation: Rise Above Colorado..59-70 2

Members and Guests Participating in the Ninth Meeting of the DEWG Convened on April 18, 2014 Adam Doyle Alia Al-Tayyib Audrey Vincent Barbara Gabella Becky Helfand Benjamin Temple Bruce Mendelson Devi Grieser Don Shriver James Henning Jim Caruso Jonathan Gray Kathleen Shoaf Katie Page Kent MacLennan Kim Meltzer Kristen Dixion Laura Pegram Laurie Lovedale Lindsey Breslin Lisa Raville M.J. Menendez Margaret Everett Matt Groves Meredith Silverstein Michelle Deland Mike Van Dyke Missi Wooldridge Nachson Zohari Ron Gowins Tarik Walker Todd Bunger Adam Doyle Alia Al-Tayyib DEA Denver Public Health Denver Health CO Dept of Public Health OBH VA/CU Anschutz Denver Office of Drug Strategy Arapahoe House Denver Police Department Denver Police Department Office of Medical Examiner Arapahoe/Douglas Mental Health Arapahoe House OMNI Institute Rise Above Colorado Arapahoe House ARTS Drug Policy Alliance Peer Assistance Services Denver Office of Drug Strategy HRAC US Attorney's Office DEA Peer Assistance Services Arapahoe House Arapahoe House CDPHE DanceSafe Denver Office of Drug Strategy ARTS - Westside HRAC Arapahoe House DEA Denver Public Health 3

AGENDA Denver Epidemiology Work Group Meeting Friday, April 18, 2014, 8:30 a.m. to Noon District 3 Police Station Community Room, 1625 S University Blvd, Denver, CO 80210 (I- 25 and University) Phone:(720) 913-1300 Welcome, introductions and packet review (8:30 to 8:40) Drug Roundtable (Data overviews and review of responses to questionnaires from law enforcement, treatment, street outreach, Medical Examiner s Office, emergency departments, Rocky Mountain Poison and Drug Center, etc.) o Summary overview of Alcohol and Other Drugs (8:40 to 8:50) o Heroin Trends (8:50-9:30) Harm Reduction Action Center Data-presentation by Lisa Raville- Executive Director Heroin Trends o Other Opioids Trends (9:30-9:50) o Alcohol Trends (9:50 to 10:10) Break: 10:10 to 10:20 Drug Roundtable continuation: o Marijuana Trends (10:20 to 10:40) o Cocaine Trends (10:40 to 10:50) o Presentation: Rise Above Colorado Presentation by Kent MacLennan- Executive Director: Colorado Teenage Drug Use & Attitude Assessment (10:50-11:10) o Methamphetamine Trends (11:10 to 11:30) o o Benzodiazepines Trends (11:30 to 11:40) o Other Drugs (if time) MDMA and Bath Salts Trends (11:40 to 11:50) Future Plans for the DEWG and Adjourn (11:50 to 12:00) 4

Purpose and Distribution The Denver Epidemiology Work Group (DEWG) has been established in response to a need identified by the Denver Drug Strategy Commission (DDSC) and the community volunteers who have served on the Drug Strategy Subcommittees for an increase in the accessibility and sharing of comprehensive local data as it relates to ongoing community-level surveillance of drug abuse in the City & County of Denver and the Denver metro area (Goal 5, Objectives 1 and 4 of the Denver Drug Strategy Plan). This report, which summarizes the quantitative and qualitative research data from the DEWG, provides current descriptive and analytical information regarding the nature and patterns, emerging trends, and social and health consequences of alcohol and drug abuse. The DEWG process is patterned after the National Institute on Drug Abuse s Community Epidemiology Work Group, and thus focuses for the most part on surveillance of illicit drug abuse, including misuse, diversion, and abuse of prescription drugs. However, alcohol use and abuse will also be examined by the DEWG on an ongoing basis. The DEWG members were selected by the Data and Evaluation Subcommittee of the DDSC based upon their expertise in substance abuse in the areas of treatment, law enforcement and intelligence, public health, research, and outreach. While all reports completed by the Denver Office of Drug Strategy (DODS) are open to the public, the distribution of this report is intended to alert the DDSC and its constituents to the current conditions and potential problems so that appropriate, timely action can be taken. This report will help to inform the efforts of the DDSC and its subcommittees during the implementation of the Denver Drug Strategy Plan and related campaigns to educate the community and, when appropriate, form policy recommendations. 5

Executive Summary This report, which summarizes the quantitative and qualitative research data from the DEWG, provides current descriptive and analytical information regarding the nature and patterns, emerging trends, and social and health consequences of alcohol and drug abuse. This report covers the latest data from various sources extending from 2004 to the first half of 2013. Areas of Current Concern: DEWG members identified specific drugs that need to be further addressed in the Denver area because of the rise in the various indicators. These include: Alcohol Marijuana Prescription drugs (other opioids) Heroin Alcohol Alcohol is the most used and abused drug in Denver as shown by both prevalence and indicator data. Alcohol use and binge use prevalence have either remained stable or increased in recent years. Prevalence data demonstrates that between 2008-2010, 65% of respondents 12 years old and over in Denver used alcohol in the past month, and during that same time period, 28.3% of the respondents engaged in binge alcohol use in the past month. Alcohol as a percentage of all treatment admissions in the Denver metro area increased from 32.9 percent in 2005 to 41.4 percent in the first half of 2013. In 2011 and 2012, there were 28,353 and 28,670 alcohol-related emergency department visits respectively. The rate of alcohol emergency department visits for 2012 in Denver Metro is approximately 5.5 times higher than the next closest drug (marijuana). From 2007 to 2012, Denver Metro alcohol hospital discharges increased from 14,465 to 18,144 while the rate increased from 538.9 to 623.1 per 100,000 or by 16 percent. Hospital discharge rates are highest among males 45 years and older with a rate of 1,454 per 100,000 in 2012. Alcohol mortality rates have remained relatively stable from 2007 to 2012. As with hospital discharges, alcohol mortality rates are also highest among males 45 years and older with a rate of 79.6 per 100,000 in 2012. Marijuana Marijuana continues to be a major drug of abuse in Denver associated with high morbidity. In the current analysis, several Denver marijuana indicators are trending upwards (Rocky Mountain Poison and Drug Center (RMPDC) calls, hospital discharges, and ED visits. Other marijuana indicators such as treatment admissions are down from the peaks in 2008 to 2010, lab tests for DUIDS are slightly down, and arrests are down. 6

For the Denver metro area, past year marijuana use increased from 2004-2006 to 2006-2008 (13.09 to 14.75 percent-not significant), and from 2006-2008 to 2008-2010 (14.75 to 17.95- significant at P <.01) for people ages 12 and over. For the Denver metro area, past month marijuana use increased from 04-06 to 06-08 (7.88 to 9.62 percent-significant <.05): and from 2006-2008 to 2008-2010 (9.62 to 12.2 percentsignificant at P<.01) for people ages 12 and over. For the Denver metro area, perception of risk decreased from 2004-2006 to 2006-2008 (30.61 to 26.82 percent-significant at P<.05): and from 2006-2008 to 2008-2010 (26.82 to 21.99- significant at P <.01) for people ages 12 and over. In the Denver metro area (Exhibit 12), marijuana treatment admissions were second only to alcohol for the entire time period shown. Such admissions increased from 2,703 in 2004 to a high of 3295 in 2008 (or by 22 percent) and remained at about that level in 2009 and 2010, 3287 and 3226 admissions, respectively. However, in 2011, marijuana admissions declined by 11 percent to 2,871; and declined again to 2,785 in 2012, or by 3 percent. For the first half of 2013, there have been 1,189 treatment admissions for marijuana. Males and those over 25 years of age increased among Denver Metro marijuana treatment admissions from 2005 to the first half of 2013. Excluding alcohol, marijuana was the most common drug as a proportion of the Denver metro area substance abuse related emergency department (ED) visits in both 2011 and 2012. Marijuana was the third most common drug (behind alcohol and prescription opioids) reported in substance abuse related hospital discharges in Denver Metro from 2008 to 2012 (Ex. 17), and was the second most common drug reported for hospital discharges in Denver County (after alcohol and cocaine) from 2007-2010 and then became the second most common drug after alcohol in 2011-2012. Other opioids (e.g., Oxycodone, Hydrocodone, Methadone, etc.) Other opioids are increasingly problematic in Denver. Prevalence has increased along with most opioid indicators including treatment admissions, ED visits, hospital discharges, and deaths. For the Denver metro area, past year non-medical use of pain relievers increased from 2004-2006 to 2006-2008 from 5.51 to 5.71 percent (not significant), and from 2006-2008 to 2008-2010 from 5.71 to 6.57 percent (not significant) for people 12 years and older. Other opioids increased nearly three-fold in the Denver metro area from 345 treatment admissions in 2004 to 909 in 2012; and jumped from 3.4 percent of total alcohol and drug treatment admissions in 2004 to 6.6 percent in 2012. Hispanics and those between 18 and 34 years of age increased among Denver Metro treatment admissions from 2005 to the first half of 2013 Prescription opioids accounted for the 3 rd most common drug in ED visits in 2011 and 2012. In Denver Metro, males and females between the ages of 18-25 years old had the highest rate of ED visits at 295.4 and 224.8 per 100,000 respectively. Prescription opioid hospital discharge rates in Denver Metro increased in all age groups from 12 years old to over 45 years from 2007-2011, and slightly started to decrease for all age groups in 2012, except for males between 18-25 years old. Overall, female rates are higher than male discharge rates in the metro area. 7

Other opioids, as a category of drugs, were among the most common drugs found in Denver drug-related decedents from 2004 to 2012. Morphine, codeine, methadone, oxycodone, hydrocodone and fentanyl accounted for 94 of the 190 drug related deaths in 2011 (49.5 percent), and 72 of the 147 drug related deaths in 2012 (49 percent) Heroin Most heroin indicators are increasing in Denver and Colorado including mortality, ED visits, treatment admissions, calls to RMPDC and samples analyzed in the Denver crime lab. Heroin treatment admissions in the Denver metro area increased by about two-thirds from 2004 (930 admissions) to 2012 (1,545 admissions). Females increased slightly among heroin treatment admissions from 32.8 to 34.2 percent from 2004 to 2012. There were increases in non-hispanic Whites (61.3 to 76.7 percent), and those 18 to 24 years old (11.7 to 33.7 percent), from 2005 to the first half of 2013. Those 45-55 years old declined from 25.7 to 7.2 percent from 2005 to the first half of 2013. Heroin represents the lowest ED rate of all of the drugs examined in this report; however ED visits rose between 2011 and 2012 in Denver County, Denver Metro and in Colorado. Denver County ED rates are higher than the metro area and for Colorado as a whole. In the Denver Metro area, heroin has the lowest hospital discharge rate compared to other drugs, but rose from 0.9 to 2.2 from 2007 to 2012. Heroin discharge rate is highest among males, 18-25 years old and increased 5 fold from a low of 2.6 per 100,000 in 2010 to a rate of 13.9 per 100,000 among this age group in 2012. The hospital discharge rate is also rising for both males and females, 26-34 years old. Cocaine While cocaine use prevalence remains stable, most cocaine indicators have been declining through 2012 (i.e., treatment admissions, mortality, hospital discharges, and calls to Rocky Mountain Poison and Drug Center). Prevalence data demonstrates or the Denver metro area, past year cocaine use increased slightly from 2004-2006 to 2006-2008 from 3.08 to 3.49 percent (not significant), and from 2006-2008 to 2008-2010 from 3.49 to 3.55 (not significant). As a primary drug, Cocaine accounted for 12% percent of Denver metro treatment admissions in the first half of 2013 behind alcohol, marijuana, methamphetamine and heroin (Ex. 15). Also, the 12.0 percent is a substantial decline from the nine year (i.e., 2004 through the first half of 2013) cocaine treatment admission peak of 23.4 percent in 2006; and is the lowest percentage during that time period. For the Denver metro area in 2012, cocaine had the 4 th highest rate of ED visits after alcohol, marijuana, and prescription opioids. During this same year, the highest rates among ED visits are males, 18-25 years old at 157.2 per 100,000 and males, 35-44 years old at 150.7 per 100,000. Cocaine ED rates declined between 2011 and 2012. 8

Cocaine accounted for the 2 nd highest discharge rate after alcohol in 2007, but dropped to the 4 th highest visits after alcohol, marijuana, and prescription opioids in 2011 and 2012. Hospital discharge rates have declined by 31% in Denver Metro from a rate of 82.5 in 2007 to 57.2, per 100,000 in 2012. Cocaine mortality rates declined 66% from 3.86 in 2007 to 1.26 per 100,000 in 2012. Methamphetamine Most methamphetamine indicators in Denver had peaked in 2005 or 2006 and declined sharply through 2008. However, from 2009 through 2012, most of the methamphetamine indicators have either stabilized or shown some small increases. Methamphetamine supply continues to be at high purity levels. Methamphetamine could not be identified separately, but rather was included in the stimulants category in ED visits, hospital discharge and mortality data. Methamphetamine treatment admissions in the Denver metro area had increased from 1,271 in 2004 to a high of 1,722 in 2007, and increased from 12 to 13.8 percent of total alcohol and drug treatment admissions. However, then methamphetamine admissions began to decline to only 1,463 (11.1 percent of total admissions) through 2011. In 2012, Denver metro methamphetamine admissions increased somewhat to 1,608 (11.5 percent of total), the highest number of admissions since 2009. For the first half of 2013, there were 787 treatment admissions which represented 12% of all treatment admissions. Stimulant ED visits related to stimulant use rose between 2011 and 2012 in Denver County, Denver Metro and Colorado. ED visits rates in 2012 in Denver Metro were highest among males, 26-34 years old at 171.3 per 100,000 and increased 39% from 2011. Stimulant related hospital visit rates for Denver County hit a peak in 2010 at 59.5 per 100,000, decreased to 48.2 per 100,000 in 2011 and rose again in to 58.6 in 2012. Compared to 2007, the stimulant related hospital discharge rate for Denver County has risen 30%. At 21.8 percent of drug samples analyzed, methamphetamine was the second most common drug submitted for testing by local law enforcement in the Denver metro area in the first half of 2013 (it had been third most common at 14.9 percent in the first half of 2012). 9

Percentage Percent Recent Alcohol and Other Drug Trends in the Denver Metro Area Alcohol Prevalence Past 30-Day Alcohol and Binge Alcohol Use from the NSDUH Exhibit 1: Past Month Alcohol and Binge Alcohol Use Among Persons 12 and Over: Denver Metro vs. Colorado vs. US--Based on 2008-10 NSDUH 70.0% 65.6% 62.5% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 51.7% 28.3% 26.8% 23.4% 2008-10 Past Month Alcohol Use (%)-12 and 2008-10 Past Month Binge Alcohol Use (%)-12 Over Pop and over Exhibit 1 compares past month alcohol 1 and past month binge 2 alcohol use for the Denver metro area 3, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the 2008-2010 NSDUHs. For the Denver metro area, 65.6 percent of respondents reported past month alcohol use, compared to 62.5 percent of their statewide counterparts. This is not a significant difference. However, both the Denver metro and Colorado respondents reported significantly higher past month alcohol use than national respondents (51.7 percent). As to binge use, 28.3, 26.8, and 23.4 percent in the Denver metro Denver Metro Area Colorado Total U.S. area, Colorado, and the U.S., respectively, reported past month binge alcohol use. None of these differences is significant. Past 30-Day Alcohol and Binge Alcohol Use Trends from the BRFSS 70.0% 60.0% 50.0% 40.0% 30.0% Exhibit 2: Adult 30-Day Alcohol Use--Denver Metro, Colorado, and US 2004 to 2011 63.3% 65.0% 66.2% 63.9% 64.3% 65.1% 65.5% 62.2% 62.2% 61.6% 62.6% 62.9% 64.3% 61.5% 60.4% 57.1% 58.4% 56.2% 57.0% 55.4% 54.8% 54.5% 54.4% 54.6% Exhibits 2 and 3 present comparisons of adult (18 and older) past 30-day alcohol and binge alcohol use for the Denver metro area 4, Colorado and the US, using data from the BRFSS. For 30-day alcohol use (Exhibit 20.0% 10.0% 0.0% 2004 2005 2006 2007 2008 2009 2010 2011 1 At least one drink of alcohol in the past month 2 Males having 5 or more drinks and females 4 or more drinks on at least one occasion in the past month. 3 In this case the Denver metro area refers to Adams, Arapahoe, Boulder, Clear Creek, Denver, Douglas, Gilpin, and Jefferson Counties. 4 For the BRFSS, the Denver metro area refers to Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, and Park Counties. Year Denver Metro Colorado US 10

Percentage 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Exhibit 3: Adult 30-day Binge Use: Denver Metro, Colorado, and US 2004 to 2011 21.0% 20.1% 18.3% 18.3% 17.8% 17.3% 17.4% 17.3% 17.5% 17.1% 16.8% 16.1% 16.2% 16.4% 16.0% 16.3% 15.1% 15.4% 15.8% 15.6% 15.8% 15.4% 15.1% 14.4% 2004 2005 2006 2007 2008 2009 2010 2011 Year Denver Metro Colorado US 2), the Denver metro area showed a slightly higher rate than Colorado and a substantially higher rate than the US for all eight years shown. As to binge use (Exhibit 3), the Denver metro area again shows a slightly higher rate than Colorado for seven out of eight years, and a somewhat higher rate than the US for all eight years. 30-Day Alcohol and Binge Use from the HKCS As previously discussed, the HKCS was conducted for the first time in the DPS during the 2008-2009 school year. It was conducted again in the 2011-12 school year (Exhibit 4 below) from 6 th through 12 th grade. As indicated in Exhibit 4, past 30- day alcohol use among DPS students ranged from 8 percent of 6 th graders to 51 percent of 12 th graders. Comparisons with the Colorado HKCS and the US YRBS are also shown from 9 th through 12 th grade, and a high school average. As indicated, DPS high school students reported a slightly higher average use (40 percent than their statewide (36 percent) or national (39 percent) counterparts. Exhibit 5 (following page) compares past30-day binge 60% 50% 40% 30% 20% 10% 0% Exhibit 4: Past 30-Day Alcohol Use Comparison Denver HKCS to Colorado and US YRBS--2011-12 8% 13% 23% 37% 36% 34% 33% 30% 22% 42% 43% 36% 56% 51% 48% 40% 39% 36% 6th 7th 8th 9th 10th 11th 12th HS Avg Denver Colorado U.S. 11

alcohol use (defined as five or more drinks in a row within a couple of hours) for DPS HKCS to the Colorado HKCS and to the US YRBS. As indicated in Exhibit 5, past 30-day binge alcohol use among DPS students ranged from 3 percent of 6 th graders to 31 percent of 12 th graders. Comparisons with the Colorado HKCS and the US YRBS are also shown from 9 th through 12 th grade, and a high school average. As shown, DPS high school students reported the average binge use (22 percent) as their statewide or national counterparts. Exhibit 5: Past 30-day Binge Alcohol Use-Comparison DPS HKCS to Colorado to US YRBS-2011-12 Alcohol Indicator Trends 45% 40% 35% 30% 25% 20% 15% 10% 3% 6% 12% 16% 14% 19% 18% For the most part, Denver s alcohol indicators are stable or increasing. Alcohol Treatment Admissions 5% Alcohol accounted 11% 20% 20% 39% 22% 0% for 41.1 percent of 6th 7th 8th 9th 10th 11th 12th HS Avg total Denver metro area treatment Denver Colorado U.S. admissions in the first half of 2013, higher than any other drug. Alcohol treatment admissions increased by 54.6 percent from 2004 (3,547 admissions) to 2012 (5,482 admissions). Likewise, alcohol as a percentage of all treatment admissions in the Denver metro area increased from 32.9 percent in 2005 to 41.4 percent in the first half of 2013(Ex. 15). While the gender percentage for alcohol admissions remained essentially the same from 2005 to the first half of 2013, Hispanics, those between 25 to 34, and those 55 and over increased slightly among alcohol admissions during that same time period (Ex. 16). 24% 25% 31% 32% 22% 22% Alcohol Emergency Department Visits Exhibit 6:Emergency Department Rate per 100,000: All Drugs (Denver Metro) In 2011 and 2012, there were 28,353 and 28,670 alcohol-related emergency department visits respectively. The rate of alcohol emergency department visits for 2012 in Denver Metro is approximately 5.5 times higher than the next closest drug (marijuana) as demonstrated in Alcohol Marijuana RX Opioid Cocaine Stimulant Heroin 984.6 990.8 176.2 153.9 121.1 110.5 73.5 84.4 63 52.6 6.9 5.4 0 200 400 600 800 1000 1200 2012 2011 12

Exhibit 6. The rate per 100,000 of alcohol related emergency department visits for 2011 and 2012 is similar to the rest of Colorado, with a Denver Metro rate of 990.8 per 100,000 in 2011 and a Colorado rate of 973.9 per 100,000, and in 2012 a Denver Metro rate of 984.6 per 100,000 and a Colorado rate of 995.5 100,000. Alcohol Related Hospital Discharges Exhibit 7: Hospital Discharge Rates: Alcohol, 2007-2011 952.26 894.82 904.51 931.04 896.13 838.83 545.19 585.71 584.41 615.94 624.46 627.58 622.77 638.24 623.13 586.01 580.92 538.87 2007 2008 2009 2010 2011 2012 Denver County Denver Metro Colorado Exhibit 7 demonstrates that the hospital discharge rate for alcohol is highest in Denver County compared to Denver Metro and Colorado. The discharge rate in Denver County peaked in 2010 and slightly decreased in 2011 and 2012. As shown in Exhibit 17, alcohol related hospital discharges in Denver Metro are substantially higher than those of any other drug. From 2007 to 2012, Denver Metro alcohol hospital discharges increased from 14,465 to 18,144 while the rate increased from 538.9 to 623.1 per 100,000 or by 16 percent. Hospital Exhibit 8 : Mortality Rates: Alcohol, 2007-2012 discharge rates are highest among males 45 years and older with a 30.28 31.77 29.12 26.3 28.17 26.62 rate of 1,454 per 100,000 in 2012. Alcohol Related Mortality 25.26 14.55 27.91 29.62 28.61 27.51 27.85 17.01 16.9 13.72 15.25 13.66 Exhibit 8 represents alcoholrelated mortality numbers (unduplicated) and rates per 100,000 for Denver County, Denver Metro and Colorado from 2007 2008 Denver County 2009 2010 Denver Metro 2011 2012 Colorado 2007 through 2012. For Denver County and Denver Metro, with some peaks and valleys, rates have been relatively stable from 2007 to 2012 with some peaks in 2008 and 2009. For Denver Metro, the rate dropped in 2012 to a rate similar in 2007, while the Colorado rate remained stable. The Denver County rate dropped slightly in 2012, after increasing in 2011. As with hospital discharges, alcohol mortality rates are also highest among males 45 years and older with a rate of 79.6 per 100,000 in 2012. 13

Number of Denver Crashes Number of Arrests Rate of Arrests Per 10,000 DUI Arrests 40000 35000 Exhibit 9: Comparison of Denver and Colorado Total Adult and Juvenile DUI Arrests: 2000-2012 36928 35031 34338 Exhibit 9 on the right 31632 31279 31691 29449 29477 compares the 30000 28059 27043 27218 number and rate of 85.1 Denver and 25000 23683 78.8 Colorado total Adult 74.5 76.2 77.9 70.2 68.7 70.5 and Juvenile DUI 68 64.2 67.9 20000 54.2 62.1 arrests from 2000 to 57.2 59.2 61.1 50 57.2 2012 Denver DUI s 15000 51.9 54.3 53.9 49.3 declined from 4145 44.8 46.3 40.7 40.5 to 2268 (or by 45.3 10000 percent) from 2000 to 2005, doubled to 4145 4531 2925 3197 3333 3660 4043 5000 2508 2280 2268 4531 by 2008; but 3276 3106 3097 then declined to 0 3097 by 2012. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Denver Adult and Juvenile DUI Arrests Colorado Adult and Juvenile DUI Arrests Denver s DUI arrest rate had declined Denver DUI Arrests Per 10000 Colorado DUI Arrests Per 10000 from 74.5 to 40.5 per 10,000 from 2000 to 2005 but then climbed dramatically to 77.9 per 10,000 by 2008. However, the Denver rate declined to 49.3 per 10,000 by 2012. Also, Denver s rate exceeded Colorado s rate from 2007 to 2012. 32484 120 100 80 60 40 20 0 Alcohol Related Fatal Crashes in Denver and Colorado Exhibit 9a shows the number of total and alcohol related fatal crashes for Denver vs. Colorado from 2004 through 2012. For Denver, alcohol related fatal crashes as a percentage of total decreased substantially from 2004 (65.5 percent) to 2008 (22.2 percent); but then increased to 2004 levels in 2009 (65.7 percent), and dropping Exhibit 9a: Number of Total and Alcohol Related Fatal Crashes: Denver Vs. Colorado for 2004-2012 (*Source: CO. Dept. of Transportation, Office of Transportation Safety) 60 50 40 30 20 10 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 Denver Fatal Crashes 58 52 31 39 45 35 35 31 34 Denver Alcohol Related Fatal Crashes 38 30 14 21 20 23 14 17 16 Colorado Fatal Crashes 596 554 485 508 473 437 411 407 434 Colorado Alcohol Related Fatal Crashes 222 224 200 209 189 184 142 168 176 600 500 400 300 200 100 0 14

Percent to 40 percent in 2010. However, in 2011 Denver alcohol related fatal crashes increased to 54.8 percent of total fatal crashes, but declined somewhat to 47.1 percent in 2012. Denver had a higher proportion of alcohol related to total fatal crashes than Colorado for the entire time period shown. Alcohol Related Calls to the Rocky Mountain Poison and Drug Center (RMPDC) From 2004 to 2013, statewide alcohol related calls to the RMPDC were at least 6 times greater than those of any other drug. From 2004 to 2013, statewide alcohol related calls to the RMPDC were at least 6 times greater than those of any other drug. The 912 calls to RMPDC in 2013, related to human exposure to beverage alcohol, represented a 4 percent decrease over 2011 (i.e., 991 calls), but constituted an overall 20% increase over the 762 alcohol related calls in 2004. Alcohol Qualitative Information Denver s high rate of alcohol use and abuse are corroborated by comments from a variety of treatment, public health/medical, research/data analysis, street outreach and law enforcement professionals. They all describe a culture that is friendly towards alcohol, especially at major entertainment and sporting events. Drinking is considered a rite of passage, and an ingrained social norm. Many parents have the attitude that kids are going to drink anyway which keeps them from getting involved with their kids when it comes to alcohol. Adolescents say it is easy to get alcohol. Clinicians describe a Front Range culture friendly to alcohol use, with a high density of alcohol retailers and advertising geared to the heavy drinkers. These clinicians also decry a lack of age relevant alcohol use prevention campaigns (similar to tobacco) and lack of alternative youth prevention programming in schools. With the expansion of Medicaid and now covering substance abuse treatment, there may be an increase of alcohol treatment admissions. Some in public health and in law enforcement see an increase in marijuana use among adolescents and young adults as going hand in hand with an increase in alcohol use (i.e., acceptability, accessibility and the idea the any substance use/abuse is okay). Marijuana Marijuana Prevalence Past Year Marijuana Prevalence: National Survey on Drug Use and Health Exhibit 10 compares past year marijuana use for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the 2004-2006, 20 15 10 5 0 Exhibit 10: Past Year Marijuana Use: Comparison of 2004-06, 2006-08 & 2008-10 NSDUH: Denver Metro, Colorado and US 17.95 16.84 14.75 13.09 13.48 12.49 10.47 11.13 10.31 Denver Area Colorado US 2004-06 2006-08 2008-10 15

Percent Percent 2006-2008, and 2008-2010 National Surveys on Drug Use and Health (NSDUHs 5 ). For the Denver metro area, marijuana use increased from 04-06 to 06-08 (13.09 to 14.75 percent-not significant), and from 06-08 to 08-10 (14.75 to 17.95-significant at P <.01). For Colorado, past year marijuana use increased from 04-06 to 06-08 (12.49 to 13.48 percent-not significant): and from 06-08 to 08-10 (13.48 to 16.84 percent- significant at P <.001). Both the Denver metro and Colorado respondents reported higher past year marijuana use than national respondents. Past Month Marijuana Prevalence: National Survey on Drug Use and Health Exhibit 10a compares past month marijuana use for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the 2004-2006, 2006-2008, and 2008-2010 NSDUHs. For the Denver metro area, past month marijuana use increased from 04-06 to 06-08 (7.88 to 9.62 percent-significant <.05): and from 06-08 to 08-10 (9.62 to 12.2 percent-significant at P<.01). For Colorado, past month marijuana use increased from 04-06 to 06-08 (7.29 to 8.56 percentsignificant P<.05): and from 06-08 to 08-10 (8.56 to 11.18 percent-significant at P<.001). Both the Denver metro area and Colorado respondents reported higher past month marijuana use than national respondents. Perception of Great Risk of Past Month Marijuana Use: National Survey on Drug Use and Health Exhibit 10b on the right compares perception of great risk of smoking marijuana once a month for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the 2004-2006, 2006-2008, and 2008-2010 NSDUHs. For the Denver metro area, perception of risk decreased from 04-06 to 06-08 (30.61 to 26.82 percent-significant at P<.05): and from 06-08 to 08-10 (26.82 to 21.99-significant at P <.01). Likewise, Colorado perception of great risk of smoking marijuana once a month also decreased from 04-06 to 06-08 (32.03 to 28.84 percent-significant at P<.05): and from 06-08 to 08-10 (from 28.84 to 24.2 percent-significant at P<.001). Both the Denver metro and Colorado respondents reported lower perception of risk of marijuana use than national respondents. 14 12 10 8 6 4 2 0 Exhibit 10a: Marijuana Use in the Past Month: Comparison of 2004-06, 2006-08, & 2008-10 NSDUH: Metro Denver vs. Colorado vs. US 12.2 11.18 50 40 30 20 10 0 7.88 8.56 7.29 6.05 6.58 6.01 5 We were expecting the 2008-10 substate and state estimates to be available for this epidemiology report. However, 2004-06 2006-08 2008-10 they will not be available until at least the summer of 2014. 9.62 Denver Area Colorado US 2004-06 2006-08 2008-10 Exhibit 10b: Perception of Great Risk of Smoking Marijuana Once a Month: Comparison of 2004-2006, 2006-2008, 2008-2010 NSDUH: Denver Metro vs. Colorado vs. US 30.61 32.03 28.84 26.82 24.2 21.99 39.1538.18 34.7 Denver Area Colorado US 16

Rate per 100,000 Marijuana Indicators Marijuana continues to be a major drug of abuse in Denver associated with high morbidity. In the current analysis, several Denver marijuana indicators are trending upwards (RMPDC calls, hospital discharges, and ED visits. Other marijuana indicators such as treatment admissions are down from the peaks in 2008 to 2010, lab tests for DUIDS are slightly down, and arrests are down. In the Denver metro area (Exhibit 15), marijuana admissions were second only to alcohol for the entire time period shown. Such admissions increased from 2,703 in 2004 to a high of 3295 in 2008 (or by 22 percent) and remained at about that level in 2009 and 2010, 3287 and 3228 admissions, respectively. However, in 2011, marijuana admissions declined by 11 percent to 2,887; and declined again to 2,845 in 2012, or by 3 percent. For the first half of 2013, there have been 1,189 treatment admissions for marijuana. Males and those over 25 years of age increased among Denver Metro marijuana treatment admissions from 2005 to the first half of 2013 (Ex. 16). Excluding alcohol, marijuana was the most common drug as a proportion of the Denver metro area substance abuse related emergency department (ED) visits in both 2011 and 2012. In Exhibit 10c, the rate of ED visits for the City and County of Denver is almost two times higher than the rate for Denver Metro and for Colorado. Rates 350 300 250 200 150 100 50 0 Exhibit 10c: Emergency Department Rate: Marijuana, 2011-2012 n=1,958 n=2,102 Denver City and County n=4,375 n=5,131 Denver Metro n=7,565 Colorado 2011 315.34 152.89 147.8 2012 331.22 176.22 179 n=9,288 for Denver Metro and Denver County are highest among males 18-25 years old, with a rate in Denver Metro rising from 534.2 in 2010 to 593.9 per 100,000 in 2011 (11% increase), and in Denver County, the rate for this group increased from 865.9 in 2010 to 1,012.6 (17% increase) per 100,000. Marijuana was the third most common drug (behind alcohol and prescription opioids) reported in substance abuse related hospital discharges in Denver Metro from 2008 to 2012 (Ex. 17), and was the second most common drug reported for hospital discharges in Denver County (after alcohol and cocaine) from 2007-2010 and then became the second most common drug after alcohol in 2011-2012. Overall, from 2007 to 2012 the marijuana hospital discharge rate increased by 57% for Denver Metro from 77.9 to 122.2 per 100,000 and increased in Denver County by 47% from 129.9 to 190.5 per 100,000. 17

From 2004 through 2009, statewide marijuana related calls to the Rocky Mountain Poison and Drug Center (human exposure only) ranked either third or fourth behind calls related to alcohol and cocaine or alcohol, methamphetamine, and cocaine. However, in 2010 (n=107), 2011 (n=98), 2012 (n=130), and 2013 marijuana calls ranked second 129.9 77.9 77.15 Exhibit 10d: Hospital Discharge Rate: Marijuana 2007-2012 146.76 154.81 89.3 90.3 87.25 89.88 behind only alcohol. The 107 marijuana calls in 2010, 98 calls in 2011, 130 calls in 2012, and 136 calls in 2013 were 98.1 percent, 81.5 percent, 141 percent increases, and 152 percent, respectively, over the 54 calls in 2009. The marijuana calls in 2010 to 2013 represented substantial increases over any of the prior years from 2004 to 2009 (Ex. 22). At 14.4 percent, cannabis was the fourth most common drug submitted for testing by local law enforcement in the Denver metro area in the first half of 2013 (Ex. 18). This is a substantial decline from the first half of 2012 when marijuana was the second most common drug tested in the Denver metro area (21 percent). Comparing the Denver metro area to Colorado and the entire US in the first half of 2013, cannabis was the third most common drug tested in Colorado (15.3 percent) and first in the entire US (32.0 percent of drug samples analyzed). The Denver Crime Lab reported analyzing 756 marijuana exhibits in 2013, down from the 876 analyzed in 2012, down slightly from the 776 exhibits analyzed in 2011, and down substantially from 1259, 1232, and 1240 marijuana exhibits analyzed in 2006, 2007 and 2008, respectively. Total adult and juvenile marijuana arrests in Denver (both sales and possession) decreased from 3,016 in 2001 to 2,110 in 2004 but then climbed steadily to 3,212 by 2007. However, from 2007 to 2008, total marijuana arrests declined by 16.9 percent to 2,670, but then increased to 3,090 in 2009 (or by 15.7 percent). However, from 2009 to 2011, total marijuana arrests declined from 3,090 to 1,545, a 50 percent decline, but in 2012, total marijuana arrests in Denver increased slightly to 1608 (Ex. 19). Linear regression was conducted on both the number of adult and juvenile marijuana arrests. For adults, the dramatic peaks and valleys in the number of arrests led to a weak correlation coefficient (R =.375) which was not significant (p =.230). However, for juveniles, the downward trend in the number of arrests was much smoother and consistent resulting in a strong correlation coefficient (R =.834) which was significant at.001. Exhibit 10e shows positive tests for persons arrested for driving under the influence of drugs in Colorado from 2009 through 2013 (2013 extrapolated based on data from first six months). These tests were conducted by the Colorado Department of Public Health and Environment, Laboratory Services Division. Positive marijuana tests tripled from 2009 (n=675) through 2011 201.2 189.08 190.51 120.8 123.2 122.2 114.18 117.48 123.65 2007 2008 2009 2010 2011 2012 Denver County Denver Metro Colorado 18

(n=2034). However, they declined slightly in 2012 (n=1989), and based on data from the first six months of 2013, declined again in 2013 (n estimated at 1590). Specifically, positive screens for marijuana were 63.3 percent of total drug screens in 2009, 70 percent of total drug screens in 2010, 75.3 percent of total drug screens in 2011, 68.7 percent of total drug screens in 2012, and 64.7 percent of total drug screens in 2013 (estimated from data for first six months of the year) 6. The DEA states that all offices within the DFD reported marijuana availability as high during this reporting period. Marijuana is widely available throughout Colorado. There has been a notable increase in both the demand for and supply of high-potency, domestically produced marijuana. In Colorado, marijuana is widely grown indoors, due in large part to state law allowing the use of marijuana for medical purposes and legalizing recreational use. A significant amount of Colorado-produced marijuana is trafficked to out-of-state markets where it commands a higher price. The Denver price for marijuana is $2000-$2,400 a pound. The Impact of Medical Marijuana By statute, CDPHE maintains a confidential registry of patients (MMR) who applied for and were entitled to receive a registry identification card 7. Substantial growth in the MMR did not start until 2009, so the MMR analysis in this section concentrates on 2009 through February 28 of 2013. Exhibit 10f shows the number of new MMR patient applications compared to medical marijuana patients with a valid registry ID (i.e., patients). The number of applications increased almost five-fold from December 2009 through February 2013 (43,769 to 210,368). The number of patients, which had also grown substantially from December 2009 through June 2011 (41,039 to 128,698), declined during the next six months to only 82,089 (or by 36.2 percent). However, by the end of June 2012, the number had increased to 99,960, or by 21.8 percent; and through February 2013, the number had further increased to 108,951 (or by 9 percent) 6 The numbers of positive drug tests completed by the Colorado Dept. of Public Health and Environment, Laboratory Services Division were somewhat different between the first two Medical Marijuana Epidemiology reports and this current one. This is due to some personnel changes along with a different methodology for selecting positive tests. 7 Details available on the Colorado Dept. of Public Health and Environment webpage, Colorado Medical Marijuana Registry. 19

Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Number There are currently 509 Medical Marijuana Centers (MMCs) conducting business in Colorado. This is a small increase from the 500 MMCs described in the January 2013 medical marijuana epidemiology report. Of the current 509 licensed MMCs, 311 (or 61.1 percent) are in the nine county Denver metro area (also a small increase from the 57.4 of MMCs in the metro area in the January report). Of the 311 MMCs in the Denver metro area: 275 (or 88.4 percent) have a Type 1 license (with 1 to 300 primary patients); 22 (or 7.1 percent) have a Type 2 license (with 301 to 500 primary patients); and 14 (or 4.5 percent) have at Type 3 license (with 501 and above primary patients). Retail Marijuana Retail marijuana shops opened in Denver on January 1, 2014. According to the Denver Business Licensing Center, as of March 24, 2014, Denver City and County has 65 licensed retail marijuana shops. Marijuana Qualitative Information The Denver Police Department stated that the marijuana illicit market is flourishing and being shipped out of state because more money can be made. Street marijuana deals are down because dealers have switched over to heroin. Exhibit 10f: Colorado Medical Marijuana Registry: Regarding the issue of lower 220,000 treatment admissions for marijuana use, a Denver 200,000 treatment clinician stated that 180,000 probation officers sometimes feel 160,000 that if they can keep a 140,000 probationer off everything else, 120,000 except marijuana, then they will 100,000 accept that and not refer to 80,000 43,769 treatment for marijuana. Another 60,000 treatment provider also stated that 40,000 marijuana takes longer to have 20,000 41,039 adverse effects on a person s life, 0 so it make take longer to see an increase in treatment admissions. Clinicians also agree that marijuana is still the number one drug of choice for youth and youth see marijuana as having very little to no risk. Synthetic Cannabinoids 240,000 Applications vs Approved Patients --Revised April 2013 99,599 95,477 125,772 116,198 148,918 128,698 177,908 163,856 82,089 Medical Marijuana Patients with a Valid Registry ID New MMR Patient Applications 195,333 210,368 107,666 108,951 96,709 20

In August 2013, Denver Public Health tracked illness and hospitalizations of people who smoked synthetic marijuana. During this time, approximately 100 cases were seen in Denver emergency rooms and approximately 250 cases were seen across Colorado emergency rooms. Paramedics described patients has having excited delirium 8 These events have been in conjunction with increasing concern among law enforcement, treatment, and street outreach personnel about the availability and use of synthetic cannabinoids including a variety of compounds with street names such as Spice, K2, and Black Mamba. Data from DAWN in the Denver metro area indicate there was no mention of synthetic cannabinoids in the participating emergency departments from 2004 through 2009. However, it started showing up in 2010 with 76 cases (a rate of 3 per 100,000 population) and in 2011 with 149 cases (a rate of 5.7 per 100,000 population). Certainly minor numbers compared to regular marijuana, but it was the first time synthetic cannabinoids had been seen in any of the institutional data sources. Likewise, data through the NFLIS indicated there were only 16 synthetic cannabinoid exhibits in 2011 in the Denver metro area, but this had increased to 271 in 2012. In addition, the Denver Crime Lab had analyzed no synthetic cannabinoid exhibits from 2000 through 2009. However, there were 4 analyzed in 2010, 9 in 2011, 84 in 2012 and 274 in 2013. Recent data from the Rocky Mountain Poison and Drug Center (RMPDC) also details the problem arising from synthetic cannabinoid use. In 2010, RMPDC received 44 human exposure calls related to synthetic cannabinoids (i.e., 36 from males and 8 from females). Symptoms reported by callers included tachycardia (abnormally rapid heart rate), confusion, agitation/irritability, dysphoria, hallucinations/delusions, nausea/vomiting, drowsiness/lethargy, tremors, mydriasis (pupil dialation), seizures, etc. Products mentioned by callers included THC Homolog, K2-herbal blend, Spice Gold-herbal blend, Spice Silver-herbal blend, and Spice Arctic Synergy-herbal blend. In June 2011, the Governor signed legislation making synthetic cannabinoids Schedule I drugs in Colorado (i.e., illicit). Denver law enforcement officers state that the Colorado law may be one of the few in the nation that s actually workable, as it covers any drug with a binding affinity similar to THC (there are over 600 such compounds that are known, but perhaps hundreds more that are unknown). However, Denver Crime Lab (DCL) chemists report that even though they may identify a compound, it is difficult to determine if it has a binding affinity similar to THC. Also, the DCL says that synthetic cannabinoids have a 3 to 6 month cycle when the chemical compounds change and then it takes awhile before the new substance can be identified (often the same packaging but different product inside). Don Shriver, the lead forensic chemist from the Denver Crime Lab, gave the following update on synthetic cannabinoids during the April 12, 2013 meeting: Regardless of what is happening on the street, synthetic cannabinoids are out of control from the crime lab s perspective. 8 Hobaica, K. (2013). Public Health Response to Synthetic Cannabinoid Outbreak. Presentation to the DEWG, October 29, 2013. 21

Percent The federal government controlled the key 5 synthetic cannabinoids, but now the DCL is seeing things coming into the lab that are marketed as being federally compliant, but contain different compounds. The DCL is playing catch up figuring out if they can find a synthetic cannabinoid, identify the cannabinoid, and show that it meets the criteria of being a synthetic cannabinoid included under Colorado legislation. The DCL sees little continuity in synthetic cannabinoid manufacturing with different compounds found in the same brand, if you look at samples purchased in different stores or on different days. Some Denver metro treatment personnel report that adolescents assessed for drug use usually know about synthetic cannabinoids, but it rarely comes up unless a client is asked about it. Some adolescents claim that they are above using synthetics, and why do so when so much high quality marijuana is available. Street outreach workers more commonly see synthetic cannabinoid users among those on probation and/or who need a clean UA. There seems to be agreement among local substance use/abuse experts that synthetic marijuana is really a misnomer in that it really doesn t have anything to do with marijuana. However, synthetic cannabinoid compounds are made to bind with cannabinoid receptors in the brain. Other Opioids Other Opioid Prevalence Exhibit 11 on the right compares past year non-medical use of pain relievers for the Denver metro area, all of Colorado and the total U.S. for respondents who are aged 12 and older based on annual averages from the 2004-2006, 2006-2008, and 2008-2010 NSDUHs. For the Denver metro area, past year non-medical use of pain relievers increased from 04-06 to 06-08 from 5.51 to 5.71 percent (not significant), and from 06-08 to 08-10 from 5.71 to 6.57 percent (not significant). Both the Denver metro and Colorado respondents reported higher past year nonmedical use of pain relievers than national respondents. Other Opioid Indicators 8 7 6 5 4 3 2 1 0 Exhibit 11: Non-Medical Use of Pain Relievers in the Past Year: Comparison of 2004-06, 2006-08 & 2008-10 NSDUH: Denver Metro vs. Colorado vs. US 5.71 5.51 5.63 5.47 Prescription opioids (e.g., oxycodone, hydrocodone, hydromorphone, meperidine, methadone, fentanyl, etc.) continue an increasing role in the Denver drug abuse scene. Such drugs as a category (i.e., Other Opioids) increased nearly three-fold in the Denver metro area from 345 6.57 6.31 4.89 Denver Metro Area Colorado US 2004-06 2006-08 2008-10 5 4.87 22

Rate per 100,000 treatment admissions in 2004 to 909 in 2012; and jumped from 3.4 percent of total alcohol and drug treatment admissions in 2004 to 6.6 percent in 2012 (Ex. 15). Hispanics and those between 18 and 34 years of age increased among Denver Metro treatment admissions from 2005 to the first half of 2013 (Ex. 16). Prescription opioids accounted for the 3 rd most common drug in ED visits in 2011 and 2012. As with marijuana, Denver County has a higher rate of ED visits compared to Denver Metro and the rest of the state as demonstrated in Exhibit 11a. In Denver Metro, males and females between the ages of 18-25 years old had the highest rate of ED visits at 295.4 and 224.8 per 100,000 respectively. Prescription opioid hospital discharge rate increased 64% from 2007 to 2012, from a rate of 85.7 to 140.7 per 100,000 in Denver Metro. Prescription opioid hospital discharge rates in Denver Metro increased in all age groups from 12 years old to over 45 years from 2007-2011, and slightly started to decrease for all age groups in 2012, except for males between 18-25 years old. Overall, female rates are higher than male discharge rates in the Denver Metro area. As with marijuana, the Denver County hospital discharge rates from 2007-2012 are higher than the metro area and the entire state as demonstrated in exhibit11b. Other opioids, as a category of drugs, were among the most common drugs found in Denver drug-related decedents from 2004 to 2012 (Ex. 20). Morphine, codeine, methadone, oxycodone, hydrocodone and fentanyl accounted for 94 of the 190 drug related deaths in 2011 (49.5 percent), and 72 of the 147 drug related deaths in 2012 (49 percent). Morphine was involved in 8.2 to 37.9 percent of Denver drug related deaths during the 2004 to 2012 time period, while codeine was involved in 0.7 to 21.3 percent during the same time period. However, due to the short half-life of the marker for heroin deaths (i.e., 6- monoacetylmorphine) and that codeine and morphine are typically present in the body following heroin use, it is likely that a substantial proportion of morphine and codeine deaths are really heroin related deaths. In fact, as heroin deaths increased dramatically in 2009-2012 due to better identification of 250 200 150 100 50 0 Exhibit 11a: Emergency Department: Prescription Opioids, 2011-2012 n=1023 n=1224 n=3161 n=3526 n=6595 n=5865 Denver County Denver Metro Colorado 2011 164.8 110.5 114.6 2012 192.9 121.1 127.1 Exhibit 11b: Hospital Discharge Rate: Prescription Opioids 2007-2012 137.79 129.06 85.72 95.86 85.61 94.49 99.94 152.96 154.58 102.68 122.35 113.82 175.06 174.44 148.76 140.74 133.94 138.8 2007 2008 2009 2010 2011 2012 Denver County Denver Metro Colorado 23

6-MAM in urine, morphine and codeine deaths dropped sharply to their lowest levels in the 2004 to 2012 time period. Oxycodone accounted for only 4 percent of Denver drug related deaths in 2004, but increased to 23.2 percent by 2009, dropping somewhat to 15.8 percent (24 deaths) in 2010. However, by 2012, oxycodone increased to the 2009 level (23.1 percent). Likewise, oxycodone in combination with any other drug accounted for only 1 death in Denver in 2005 and 2006 combined. However, from 2007 through 2012, oxycodone in combination with other drugs ranged from 10.1 to 21.1 percent of Denver drug mortality (Ex. 21). Taken together, oxycodone and hydrocodone accounted for 2.8 percent of drugs submitted for testing by local law enforcement in the Denver metro area in the first half of 2013 (n = 180). In comparison, oxycodone and hydrocodone constituted 3.5 and 5.7 percent of drug samples analyzed in Colorado and the US, respectively (Ex. 18). Overall, other opioid exhibits tested by the Denver Police Department crime lab increased nearly five-fold from 46 in 2001 to 211 in 2012 (Ex. 25). In addition, the 226 other opioid exhibits analyzed by DCL in 2013 is the most in the 2001 to 2013 time period. Overall, as shown in Exhibit 23, the trend for other opioid exhibits analyzed by the Denver Crime Lab (DCL) from 2001 through 2013 represents a statistically significant increase (p <.001). As shown in Exhibit 25, Oxycodone exhibits analyzed by the DCL have increased dramatically from 30.4 percent of opioids analyzed in 2001 to 49.8 percent in 2012, and 47.3 percent in 2013. Conversely, hydrocodone exhibits have declined from a high of 46.7 percent in 2003 to 22.6 percent in 2013. Morphine exhibits analyzed have shown peaks and valleys for the time period shown ranging from a high of 15.5 percent in 2004 to a low of 4.3 percent in 2002. Morphine exhibits accounted for 13.3 percent of opiate exhibits analyzed in 2013. Recent data from the Colorado Prescription Drug Monitoring Program (PDMP) shows a mixed picture in the number and rate of hydrocodone and oxycodone prescriptions filled for Denver residents 9. Exhibit 26 details hydrocodone prescriptions filled for Denver residents from the first quarter of 2008 through the fourth quarter of 2013. Hydrocodone prescriptions peaked at 48,723 or 81.72 per 1000 population, in the first quarter of 2012, but declined to 41,675 (or 69.03 per 1000 population) by the fourth quarter of 2013. Overall, from the first quarter of 2008 through the fourth quarter of 2013, the hydrocodone prescription rate decreased slightly from 76.14 to 69.03 per 1000, or by 9.3 percent. Oxycodone prescriptions dispensed in Denver increased from 31,575 to 43,332 from the 1st quarter of 2008 through the 4 th quarter of 2011, with the rate per 1000 population increasing during the same time period from 54.42 to 72.80. This is an increase of 33.8 percent (Ex. 25). However, they then declined to 40,205 through the fourth quarter of 2013, while the rate also declined to 66.59 (or by 8.5 percent). Overall, from the first quarter of 2008 through the fourth quarter of 2013 the oxycodone prescription rate increased from 54.42 to 66.59 per 1000 (or by 22.4 percent). Other Opioids Qualitative Information Public health specialists feel that it is very easy to access prescription drugs. Family and friends are the most likely first source of prescription drugs. The DEA examined (unscientifically) how 9 The Denver Office of Drug Strategy was notified in July 2010 by the Colorado Department of Regulatory Agencies, Board of Pharmacy that past data on prescriptions filled in Denver was incorrect. The corrected data was included in both the October 2010 and April 2011Denver Drug Trends reports. Please do not use prior data. 24

Rate per 100,000 many opioid deaths received drugs from a prescriber, and found difficult to find an original prescriber. The DEA stated that a lot of the traffic on the internet has quieted down because of new rules (excluding Silk Road). A U.S. Attorney stated that it is very difficult to track drugs on Silk Road because of the bitcoin system and many drugs are available. Treatment clinicians are finding an association between prescription drugs and heroin, with many patients starting with prescription drugs and then switching to heroin. Heroin Indicators Heroin Most heroin indicators are increasing in Denver and Colorado including mortality, ED visits, treatment admissions, calls to RMPDC and samples analyzed in the Denver crime lab. Heroin treatment admissions in the Denver metro area increased by about two-thirds from 2004 (930 admissions) to 2012 (1,545 admissions). In addition, as a percentage of total admissions in the Denver metro area, heroin had declined somewhat from 13.2 percent of primary drugs in 2004 to 10.7 percent in 2008, but then began a steady increase to 18.3 percent in 2012. While heroin had been behind alcohol, marijuana, cocaine and methamphetamine in 2004, it surpassed cocaine in both 2011 and 2012 (though still remained behind alcohol, marijuana and methamphetamine Ex. 15). Females increased slightly among heroin treatment admissions from 32.8 to 34.2 percent from 2004 to 2012. There were increases in non- Hispanic Whites (61.3 to 76.7 percent), and those 18 to 24 years old (11.7 to 33.7 percent), from 2005 to Exhibit 12: Emergency Department Rate: Heroin 2011-2012 15 10 Denver County Denver Metro Colorado 2011 11.6 5.38 4.49 2012 12.29 6.9 6.4 the first half of 2013. Those 45-55 years old declined from 25.7 to 7.2 percent from 2005 to the first half of 2013. Also, those who smoke heroin increased from 9.6 percent of heroin treatment admissions in 2005 to 21.7 percent in the first half of 2013. Conversely, those who inject heroin declined from 83.2 to 70.3 percent of heroin admissions during the same time period (Ex.16). Heroin represents the lowest ED rate of all of the drugs examined in this report; however ED visits rose between 2011 and 2012 in Denver County, Denver Metro and in Colorado. Denver County ED rates are higher than the metro area and for Colorado as a whole. 5 0 n= 72 n=78 n=154 n=201 n=230 n=332 25

Rate per 100,000 Rate per 100,000 In the Denver Metro area, heroin has the lowest hospital discharge rate compared to other drugs, but rose from 0.9 to 2.2 from 2007 to 2012. Heroin discharge rate is highest among males, 18-25 years old and increased 5 fold from a low of 2.6 per 100,000 in 2010 to a rate of 13.9 per 100,000 among this age group in 2012. The hospital discharge rate is also rising for both males and females, 26-34 years old. Hospital discharge rates for Denver County were higher than Denver Metro and Colorado from 2007-2011 and then dropped below the rates of Denver Metro and Colorado in 2012. Mortality rates were quite low for all three areas, with Denver County mortality rates declining slightly between 2011 and 2012 and rising for both Denver Metro and Colorado slightly from 2010-2012 as demonstrated in exhibit 12b. Heroin increased from 4.0 to 27.9 percent of Denver drug related decedents from 2004 to 2012. The reason for this discrepancy had to do with detection of 6-monoacetylmorphine (6-MAM) in the blood and/or urine toxicology of the deceased as part of the autopsy. Heroin is metabolized into 6-MAM then into morphine. Also, heroin typically contains codeine because codeine naturally occurs in the opium poppy plant (from which heroin is produced). The 6-MAM needs to be present to confirm that heroin was related to the cause of death. However, this metabolite has a very short half-life and may be undetectable by the time blood work is done as part of an autopsy; whereas morphine and codeine will very likely be present in the blood toxicology. Starting in 2008, the Denver Office of the Medical Examiner (OME) began efforts to more definitively diagnose heroin mortality due to changes in the lab testing they use (i.e., looking for 6-MAM in urine). As a result, more heroin deaths were identified in 2008 (N=27), 2009 (N=49), 2010 (N=35), 2011 (N=49) and 2012 (N=41) than in any year from 2003 through 2007. Consequently, the number of morphine and codeine deaths has declined, especially in 2010 through 2012 (Ex. 20). The combination of heroin and cocaine (typically called a speedball) was found among 2.6 to 11.1 percent of Denver drug related decedents from 2005 to 2012 (Ex. 21). Exhibit 12a: Hospital Discharge Rate: Heroin 2007-2012 5 4 3 2 1 0 2007 2008 2009 2010 2011 2012 Denver County 3.33 3.44 4.03 2.31 4.03 1.42 Denver Metro 0.97 1.35 2.09 1.17 2.06 2.2 Colorado 0.87 1.41 1.81 1.11 2.09 2.64 Exhibit 12 b: Mortality Rates: Heroin 2007-2012 2 1.5 1 0.5 0 2007 2008 2009 2010 2011 2012 Denver County 0.7 0.92 1.85 1.16 1.29 0.89 Denver Metro 0.42 0.48 0.72 0.45 0.62 0.61 Colorado 0.27 0.31 0.48 0.3 0.52 0.58 26

The OME states they are still seeing deaths with both opiates (e.g., heroin) and uppers (primarily cocaine). However, frequently, when cocaine is involved in mortality there is only the benzoylecgonine metabolite in the toxicology. This suggests the use of heroin/opiate and cocaine is not simultaneous, with cocaine use prior to heroin/opiate. Some Denver clinicians who are also involved in outreach and research emphasize that heroin related mortality is often a result of polydrug abuse, particularly heroin and benzodiazepines (this also shows up in the OME heroin mortality data). Additionally, many heroin overdoses are caused by decreased tolerance (e.g., addicts who have been in prison who use when released). Statewide, heroin/morphine human exposure calls to the Rocky Mountain Poison and Drug Center from 2004 through 2013 have mostly ranked behind those of alcohol, cocaine, marijuana and methamphetamine. Such calls had also remained relatively stable from 2004 to 2010 with a peak of 29 calls in 2009 and a low point of 19 calls in 2010. However, in 2011 heroin/morphine related human exposure calls to RMPDC increased 2.5 fold to 47, with a small increase to 50 calls in 2012, and remaining relatively stable at 44 calls in 2013. The 2011, 2012 and 2013 heroin calls are the highest numbers of such calls in the nine-year time period shown (Ex. 22). At 15.4 percent of samples tested, heroin lagged behind cocaine and methamphetamine among drugs submitted for testing by local law enforcement in Denver in the first half of 2013. In comparison, heroin (at 12.2 percent of samples tested) ranked fourth behind cocaine, marijuana and methamphetamine in the first half of 2012. As to comparisons with Colorado and the US in the first half of 2013, heroin constituted 12.4 percent of drug samples analyzed in Colorado, and 9.9 percent of samples analyzed in the entire US (Ex. 18). The Denver Crime Lab reported analyzing 875 exhibits in 2013 44.2 percent more than the 607 heroin exhibits in 2012, and nearly three times as many as the 304 heroin exhibits in 2011. It is also the highest number of heroin exhibits analyzed in the 2001 to 2013 time period. Heroin Qualitative Information A treatment clinician who provides methadone treatment stated that most people who come in for treatment of heroin addiction started on prescription drugs and switched to heroin. Another treatment provider stated that treatment percentages for methadone treatment may be down because more young people are willing to engage in treatment and because their heroin use has not been that long, they enter drug free treatment. Another explanation may be that youth are receiving suboxone from a private physician and participating in drug free treatment. It was suggested that the medical community needs more education on the association between prescription drugs and heroin use once they no longer receive pain medication. The State Consortium on Prescription Drugs is working on this issue. The DEA reported that heroin comes in from Mexico and Hondurans are selling it on the street where it gets cut down another 20%. The DEA says the current purity is 27-30% and this is why we may see an increase in hospital or ED admissions because the heroin may be cut with other substances. 27

Rate per 100,000 Percent Cocaine Cocaine Prevalence Exhibit 13 compares past year 2.8 3 2.38 cocaine use for the Denver metro 2.33 1.94* area, all of Colorado and the total 2 U.S. for respondents who are aged 12 and older based on annual averages from the 2004-1 0 2006, 2006-2008, and 2008-2010 Denver Metro Area Colorado US NSDUHs. For the Denver metro area, past year cocaine use increased slightly from 04-06 to 2004-06 2006-08 2008-10 06-08 from 3.08 to 3.49 percent (not significant), and from 06-08 to 08-10 from 3.49 to 3.55 (not significant). Both the Denver metro and Colorado respondents reported higher past year cocaine use than national respondents. Cocaine Indicators While cocaine use prevalence remains stable, most cocaine indicators have been declining through 2012 (i.e., treatment admissions, emergency department visits, mortality, hospital discharges, and calls to Rocky Mountain Poison and Drug Center). There is still some evidence that the cocaine user population is aging. For example, the proportion of cocaine clients in treatment who are 45 and over has more than doubled in the last nine years. As a primary drug, Cocaine accounted for 12% percent of Denver metro treatment admissions in the first half of 2013 behind alcohol, marijuana, methamphetamine and heroin (Ex. 15). Also, the 12.0 percent is a substantial decline from the nine year (i.e., 2004 through the first half of 2013) cocaine treatment admission peak of 23.4 percent in 2006; and is the lowest percentage during that time period. African-Americans and those 45 and older increased among Denver cocaine treatment admissions from 2004 to first half of 2013. However, cocaine route of administration proportions remained stable during the same time period (Ex. 16). For the Denver metro area in 2012, cocaine had the 4 th highest rate of ED visits after alcohol, marijuana, and prescription opioids. During this same year, the highest rates among ED visits are males, 18-25 years old at 157.2 per 100,000 and males, 35-44 years old at 150.7 per 100,000. Cocaine ED rates declined between 2011 and 2012, but Denver County has higher ED rates than the Denver Metro and Colorado (Ex. 13a). 4 Exhibit 13: Cocaine Use in Past Year: Comparison of 2004-06, 06-08 & 08-10 NSDUH: Denver Metro vs. Colorado vs. US 3.08 3.49 3.55 3.24 3.44 Exhibit 13a: Emergency Department Rate: Cocaine, 2011-2012 250 200 150 100 50 0 n=1261 n=1092 Denver County n=2416 n=3684 Denver Metro n=2141 Colorado 2011 203.09 84.43 71.97 2012 172.07 73.53 61.92 n=3,213 28

Cocaine accounted for the Rates: Cocaine, 2007-2012. 2 nd highest discharge rate 250 225.97 after alcohol in 2007, but 211.38 dropped to the 4 th 194.1 195.58 highest 200 181.02 visits after alcohol, 148.28 marijuana, and prescription 150 Denver County opioids in 2011 and 2012. 96.22 Hospital discharge rates 100 85.46 76.89 80.07 77.96 Denver Metro 65.29 have declined by 31% in Colorado Denver Metro from a rate of 50 82.5 72.07 65.56 67.92 65.88 96.2 in 2007 to 65.2, per 57.18 100,000 in 2012. Denver 0 County has higher hospital discharge rates than Denver 2007 2008 2009 2010 2011 2012 Metro and Colorado but these rates declined by 34% from 2007 to 2012 as demonstrated in Ex. 13b. After alcohol, cocaine had been the second most common drug reported in substance abuse related hospital discharges in Denver from 2003 to 2009 (Ex. 17). However, in 2010 the cocaine hospital discharge rate fell to third behind alcohol and marijuana, and to fourth behind alcohol, marijuana and opioids in 2011 and 2012. In fact, after increasing steadily from 254 to 331 per 100,000 population from 2003 to 2006, the cocaine discharge rate declined almost steadily to only 188 per 100,000 by 2012 (or by 43.2 percent). In Denver Metro, cocaine was the 4 th most common drug found in mortality rates from 2007 to 2012 after alcohol, prescription opioids, and other opioids. Cocaine mortalities have been declining 2007 to 2012 in Denver County, Denver Metro and in Colorado (Ex. 13c). Cocaine mortality rates declined 66% from 3.86 in 2007 to 1.26 per 100,000 in 2012. Cocaine was the most common drug found in Denver drug related decedents from 2005 to 2007, and behind only alcohol in 2004, and 2008 to 2011 (Ex. 20). However, the percentage of cocaine among total drug decedents declined from a peak of 50.3 percent of decedents in 2006 to 25.6 percent in 2009, rising slightly to 28.9 percent of decedents in 2011. However, in 2012, cocaine declined to only 17 percent of drug decedents (25 deaths), the lowest percentage in the study period of 2003 to 2012. Cocaine in combination with other drugs (e.g., alcohol, heroin) was among the most common combinations found in Denver drug related Exhibit 13b; Hospital Discharge Exhibit 13c: Mortality Rates: Cocaine, 2007-2012 Denver County Denver Metro Colorado 3.86 3.49 3.41 2.79 2.2 1.92 1.45 1.24 1.26 0.96 1.08 0.86 1.25 1.06 0.82 0.69 0.84 0.63 2007 2008 2009 2010 2011 2012 29

decedents in the 2005 to 2012 time period (Ex. 21). Cocaine related human exposure calls to the Rocky Mountain Poison and Drug Center (RMPDC) had declined overall from 120 in 2004 to 64 in 2010, but such calls had surged to 96 in 2011. The cocaine calls then declined to 64 in 2012, but rebounded to 80 in 2013. The cocaine calls for each year from 2007 to 2013 are still well below the peak of 129 calls for 2006 (Ex. 22). Cocaine was the most common drug submitted for testing by local law enforcement in the first half of 2013 in the Denver metro area (i.e., Denver, Arapahoe and Jefferson Counties Ex. 19). As shown, cocaine accounted for 25.1 percent of the samples analyzed in the Denver metro area compared to 22.2 percent for all of Colorado, and 14.9 percent for the entire US. In 2013, the Denver Crime Lab (DCL) analyzed 779 crack cocaine exhibits down slightly from the 790 analyzed in 2012, but down substantially from the peak of 1740 exhibits in 2005. As to powder cocaine, in 2013 the DCL analyzed 631 exhibits up from the 533 exhibits in 2012, and the 521 analyzed in 2011; but down substantially from the peak of 1240 in 2002. Cocaine Qualitative Information The cocaine trends remain low in Denver. One treatment clinician stated that there is greater availability of prescription drugs and other drugs and that cocaine is expensive. The DEA stated that they have not seen changes in price and purity but that the supply is tightening up in Mexico. In addition, methamphetamine is much cheaper. Cocaine remains popular among street IDU s for speedballs (cocaine and heroin injected at the same time a common combination found in Denver drug mortality cases). Methamphetamine Most methamphetamine indicators in Denver Metro had peaked in 2005 or 2006 and declined sharply through 2008 and 2009. However, from 2009 through 2012, most of the methamphetamine indicators have either stabilized or shown some small increases. Methamphetamine treatment admissions in the Denver metro area had increased from 1,271 in 2004 to a high of 1,722 in 2007, and increased from 12 to 13.8 percent of total alcohol and drug treatment admissions. However, then methamphetamine admissions began to decline to only 1,463 (11.1 percent of total admissions) through 2011. In 2012, Denver metro methamphetamine admissions increased somewhat to 1,608 (11.5 percent of total), the highest number of admissions since 2009. For the first half of 2013, there were 787 treatment admissions which represented 12% of all treatment admissions. Methamphetamine was the fourth most common drug among total alcohol and drug treatment admissions in the Denver metro area in 2004, and 2006 through 2008; and third most common in 2005, and 2009 through 2012 (Ex. 15). There was little change in the gender proportion of methamphetamine treatment admissions from 2005 to 2012. However, during the first half of 2013, male treatment admission increased slightly by 4.6%. During this time period the proportion of Hispanics increased from 13.3 to 17.2 percent of meth admissions. Likewise, clients 25-34 years old increased among Denver metro methamphetamine treatment admissions from 2005 to the first half of 2013 and for those 45-54 30

years old, increased from 7.8% of treatment admissions in 2005 to 14.6% in the first half of 2013. The route of administration for methamphetamine treatment admissions changed very little during this time period (Ex. 16). Exhibit 14: Emergency Department Rates: Stimulants, 20011-2012 82.46 104.31 52.63 62.95 60.8 74.24 Methamphetamine could not Denver County Denver Metro Colorado be identified separately, but rather was included in the 2011 2012 stimulants category in ED, hospital discharge and mortality data. ED visits related to stimulant use rose between 2011 and 2012 in Denver County, Denver Metro and Colorado as demonstrated in Exhibit 14. ED visits rates in 2012 in Denver Metro were highest among males, 26-34 years old at 171.3 per 100,000 and increased 39% from 2011. Males 18-25 years old had the next highest rate at 152.5 per 100,000 but this was only a slight increase from 2011. Stimulant related hospital discharge rates remained fairly stable for Denver Metro and Colorado and have slightly risen between 2011 and 2012. Stimulant related hospital visit rates for Denver County hit a peak in 2010 at 59.5 per 100,000, decreased to 48.2 per 100,000 in 2011 and rose again in to 58.6 in 2012. Compared to 2007, the stimulant related hospital discharge rate for Denver County has risen 30%. Stimulant related mortalities are low for the 3 areas, with a range of 11 to 21 deaths in Denver County from 2007 to 2012, a range of 27-46 deaths for Denver Metro during the same time period, and a range of 53-83 deaths in Colorado from 2007 to 2012. Methamphetamine accounted for 20, or 10.5 percent of the 190 alcohol and drug related deaths in Denver in 2011, declining to 12 deaths (8.2 percent of 147 total deaths) in 2012. The methamphetamine death percentages from 2010 through 2012 were the highest recorded in the 2004 through 2012 time period (Ex. 22). Methamphetamine related calls to the Rocky Mountain Poison and Drug Center increased from 95 to 127 from 2004 to 2005, but then declined sharply to only 29 calls in 2006; and remained at that level in 2007 (31 calls). 45.23 38.72 31.14 Exhibit 14a: Hospital Discharge Rates: Stimulants, 2007-2012 38.49 39.46 29.6 32.21 26.07 28.31 59.52 48.15 41.13 39.48 36.3 33.86 58.62 45.58 36.99 2007 2008 2009 2010 2011 2012 Denver County Denver Metro Colorado 31

However, methamphetamine calls then increased steadily, more than doubling to 78 calls in 2011, remaining at about that level in 2012, 72 calls, but then increasing sharply to 117 calls in 2013 (the highest total since 2005 when most methamphetamine indicators were peaking) (Ex. 20). At 21.8 percent of drug samples analyzed, methamphetamine was the second most common drug submitted for testing by local law enforcement in the Denver metro area in the first half of 2013 (it had been third most common at 14.9 percent in the first half of 2012). Also, in the first half of 2013, methamphetamine ranked first among drug samples analyzed in Colorado (26.6 percent) and third among drug samples analyzed in the entire US (14.2 percent) (Ex. 18). The Denver Crime Lab (DCL) analyzed 998 methamphetamine exhibits in 2013, up nearly 62 percent from the 617 methamphetamine exhibits in 2012, and nearly triple the 341 exhibits analyzed in 2011. In fact the 998 exhibits analyzed in 2013 were the most during the entire 2001 through 2013 time period. Methamphetamine Qualitative Information The DEA reports that most of the methamphetamine in Colorado is produced and supplied by Mexican Drug Trafficking Organizations via the larger laboratories in Mexico. The DEA also reports that methamphetamine availability is both high and stable over the last few years. A handful of organizations control the Mexican super labs. Methamphetamine purity is currently very high with recent samples analyzed at almost 100% percent purity which is why we may be seeing increases. Benzodiazepines Benzodiazepines (benzos) are a class of psychoactive drugs with varying sedative, hypnotic, and anti-anxiety (i.e., anxiolytic) properties. Most common are the benzodiazepine tranquilizers (e.g., diazepam or Valium, alprazolam or Xanax, lorazepam or Ativan, etc.). Benzos present a mixed picture in the Denver drug scene, with mortality rates stable and decreasing slightly in 2012 and crime lab exhibits showing an upward trend. This drug category is not shown as a separate breakout on Exhibit 12. However, from 2002 to 2012 benzos were infrequent among Denver metro area treatment admissions accounting for a high of 61 admissions in 2012, and 28 admissions in the first half of 2013 (0.5 percent of total drug admissions including alcohol) to a low of 29 in 2010. Diazepam, alprazolam, and clonazepam (combined) have grown from 9.3 to 28.5 percent of Denver alcohol and drug mortality from 2004 to 2012 (Exhibit 20). Likewise, benzodiazepines in combination with opiates (including heroin) have constituted 7.1 to 21.8 percent of alcohol and drug mortality in Denver from 2005 through 2012 with the highest percentages seen in 2011 and 2012, 20 and 21.8 percent respectively. The Denver Police Department crime lab analyzed 140 benzo exhibits in 2013, almost twice as many as the 84 benzo exhibits in 2012, and the 79 benzo exhibits analyzed in 2011. The 140 benzo exhibits in 2013 was easily the highest total of benzo exhibits analyzed by the DCL in the 2001 through 2013 time period. Overall, as shown in Exhibit 27, the trend for other benzos exhibits analyzed by the Denver Crime Lab (DCL) from 2001 through 2013 represents a 32

statistically significant increase (p <.001). Most notable among these benzo exhibits, alprazolam (i.e., Xanax) nearly doubled from 24.3 percent to 46.8 percent from 2001 through 2011, declining slightly to 44 percent of total benzo exhibits in 2012 and to 40.7 percent in 2013 (Ex. 28). As to other benzos in 2013, clonazepam was second to alprazolam in percent of benzo exhibits (at 31.4 percent), followed by diazepam (17.1 percent) and lorazepam (9.3 percent). In Exhibit 30, PDMP data show overall increases in the rate of lorazepam, alprazolam, and diazepam prescriptions filled for Denver residents from the 1st quarter of 2008 through the 4 th quarter of 2013. As indicated, among the three benzos, lorazepam had the highest rate of prescriptions filled for Denver residents for the entire time period shown, followed by alprazolam with diazepam third 10. Benzodiazepines Qualitative Information Local clinicians state that benzodiazepines are popular with people using opioids because of the high it creates when taken together (is thought to stretch the effects of heroin ). Some opioid addicts may use benzodiazepines to manage the effects of opioid withdrawal (e.g., a Denver detox manager sees a number of heroin using clients self-admitting to detox seeking benzodiazepine medication when they are unable to get heroin). However, the synergistic effects of opioids and benzodiazepines (often in combination with alcohol as well) can be lethal. The Office of the Medical Examiner sees stated related deaths usually include a mix of benzodiazepine and opioids. Methylenedioxymethamphetamine (MDMA) MDMA, or ecstasy, morbidity and mortality remain relatively low in the Denver metro area, but some indicators have increased. MDMA treatment admissions have increased from only 3 in 2002 to 76 and 70 in 2011 and 2012, respectively (.6 and.5 percent, respectively of total alcohol and drug admissions) and 39 admissions for the first half of 2013. Exhibit 29 shows MDMA and MDMA substitute (e.g., MDMA and methamphetamine, MDMA and ketamine, etc.) exhibits analyzed by the Denver Police Dept. crime lab from 2001 through 2013. In 2001, nearly all (110 or 98.2%) of the 112 MDMA/MDMA substitute exhibits were pure MDMA. However, while total MDMA/MDMA substitute exhibits increased to 192 and 173 in 2007 and 2008, respectively; the percentage that were pure MDMA dropped to 52.6 percent in 2007 and 61.3 percent in 2008. In 2009, there were 156 MDMA/MDMA substitute exhibits with only 48 percent being pure MDMA; in 2010, 74 of 117 (or 63.2 percent) of MDMA/MDMA substitute exhibits were pure MDMA; in 2011, 45 of 74 (or 61 percent) of MDMA/MDMA substitute exhibit were pure MDMA; in 2012 only 22 of 47 (or 46.8 percent) of MDMA/MDMA substitute exhibits were pure MDMA; and in 2013 22 of 28 (or 78.6 percent) of MDMA/MDMA substitute exhibits were pure MDMA. 10 The Denver Office of Drug Strategy was notified in July 2010 by the Colorado Department of Regulatory Agencies, Board of Pharmacy that past data on prescriptions filled in Denver was incorrect. The corrected data was included in both the October 2010 and April 2011Denver Drug Trends reports. Please do not use prior data.. 33

Denver police are currently seeing more Molly rather than MDMA in powder. Molly is also being seen among the dance community, which is also a community of poly drug users which may include, MDMA, marijuana, LSD and alcohol. MDMA in powdered form sells for $1000 to $1600 per ounce. MDMA tablets sell for $8-25 per dosage unit (e.g., tablet). Users can get lower price deals for higher quantity purchases. Undercover officers are encountering powdered MDMA in gel caps called Mollies that are approximately.2 grams and sell for $15/du. The Denver Crime Lab finds that most MDMA tabs are cut with other drugs (e.g., methamphetamine, benzylpiperazine, etc.) but sold as MDMA (see Exhibit 29). One MDMA sample analyzed by the DEA in 2011 was only 22 percent pure. Benzylpiperazine (BZP) and Trifluoromethylphenylpiperazine (TFMPP In 2012 the Denver Crime Lab analyzed 20 BZP samples, 0 BZP/MDMA combinations, and 2 TFMPP exhibits; compared to 18 BZP exhibits, 1 BZP combination and 0 TFMPP in all of 2011. However, this is compared to the DCL analysis of 10 BZP, 14 BZP combinations, and 1 TFMPP exhibit for all of 2010. In contrast, the DCL had analyzed zero BZP, BZP combinations, and TFMPP exhibits from 2001 through 2007. The DCL says the BZP combinations may relate to BZP recently being made a Schedule 1 controlled substance. CY 2010 was the first year that BZP was illegal in Colorado and cases could be prosecuted with less than 1000 tabs. Unfortunately, BZP is not reported (at least currently) in treatment, emergency room, mortality, or hospital discharge data. It seems only the crime labs are isolating this drug. Thus, it is difficult to determine actual BZP usage levels. However, local law enforcement report somewhat of a resurgence in BZP (BZP is often sold as ecstasy). According to a recent DEA review, BZP was first synthesized in 1944 as a potential antiparasitic agent; and was subsequently shown to have amphetamine-like effects. Though much less potent than amphetamine, BZP acts like a stimulant in humans producing euphoria, and increased heart rate and blood pressure. It appears that 1996 was the first year BZP use was initiated by drug abusers in the US, as measured mostly by encounters with law enforcement. BZP is usually taken orally as a powder, tablet or capsule. BZP street names include A2, Legal E, or Legal X. BZP is often taken in combination with a substance known as TFMPP (1-3- trifluoromethylphenylpiperazine), which is touted as a substitute for MDMA. Though probably not a significant problem in Denver in terms of user numbers, recent research 11 points out that BZP and TFMPP, when taken together, have a synergistic effect on certain neurotransmitters (i.e., dopamine and serotonin) which may lead to seizures. The Denver Crime Lab has reported seeing some methamphetamine mixed with TFMPP to boost the psychedelic effect. 11 Bauman, et al. N-Substituted Piperazines Abuse by Humans Mimic the Molecular Mechanism of 3,4 Methylenedioxymethamphetamine. Neuropsychopharmacology, 2005, 30: 550-560 34

Bath Salts A class of drugs recently appearing on the scene in the Denver metro area and in Colorado is the synthetic stimulant called bath salts. Marketed with such benign sounding names as Cloud Nine, Vanilla Sky, Bliss and White Dove, these stimulants have effects similar to methamphetamine and ecstasy. The actual names for these drugs include mephedrone, methylone and MDPV. The Denver Crime Lab (DCL) analyzed 15 bath salts (e.g., butylone, methylone, MDPV, and various combinations) among the total samples analyzed in 2011, 41 in 2012 and 9 in 2013. However, these drugs do not typically appear in any other institutional data sets at this point, with the exception of the Rocky Mountain Poison and Drug Center. According to the RMPDC, based on data from January through April, 2011, there were 9 exposures to bath salts (8 males and 1 female). These bath salt users reported twenty-one different symptoms including slurred speech, seizures, hypertension, excessive sweating, acidosis, chest pain, confusion, agitation and irritability, and tachycardia. Though as mentioned above, bath salts are not in the treatment data set, one Denver area treatment program reports an increase in bath salts use, mainly males in their late 20 s to early 30 s (and actually had one client who had injected bath salts). The National Institute on Drug Abuse s, Community Epidemiology Work Group, considers these synthetic cathinones to be an emerging threat (including MDPV, mephedrone, methylone, 4- FMC 4-fluoromethcathinone- and 3-FMC 3-fluoromethcathinone). This class of drugs has been huge in Europe since 2007 with horrific stories of psychotic episodes. Any information on the effects and consequences of this class of drugs is anecdotal. The DEWG will continue to monitor these drugs to try and determine their effects within the Denver metro area. 35

Exhibit 15: Numbers and Percentages of Treatment Admissions by Primary Drug Type in Denver Metro Area: CY 2005 2013 (first half) Drug 2005 2006 2007 2008 2009 2010 2011 2012 2013(1h) Total Alcohol n 3,579 4,415 4,448 5,088 5,266 4,964 5,078 5,631 2,691 41,160 % 32.9 35.9 35.7 37.0 38.1 37.3 38.1 39.4 41.1 37.2 Marijuana n 2,694 2,904 2,928 3,295 3,289 3,228 2,887 2,845 1,189 25,259 % 24.8 23.6 23.5 23.9 23.8 24.3 21.7 19.9 18.1 22.8 (excluding alcohol) % 37.0 36.8 36.6 38.0 38.4 38.7 35.1 32.9 30.8 36.3 Methamphetamine n 1,494 1,699 1,722 1,714 1,640 1,562 1,473 1,643 787 13,734 % 13.8 13.8 13.8 12.5 11.9 11.7 11.1 11.5 12.0 12.4 (excluding alcohol) % 20.5 21.5 21.5 19.7 19.1 18.7 17.9 19.0 20.4 19.8 Cocaine n 1,462 1,848 1,861 1,910 1,602 1,354 1,274 1,239 465 13,015 % 13.5 15.0 15.0 13.9 11.6 10.2 9.6 8.7 7.1 11.8 (excluding alcohol) % 20.1 23.4 23.3 22.0 18.7 16.2 15.5 14.3 12.0 18.7 Heroin n 1,029 827 846 925 1,061 1,149 1,352 1,580 831 9,600 % 9.5 6.7 6.8 6.7 7.7 8.6 10.2 11.1 12.7 8.7 (excluding alcohol) % 14.1 10.5 10.6 10.7 12.4 13.8 16.4 18.3 21.5 13.8 Other Opioids 1` n 457 433 429 570 684 783 834 923 418 5,531 % 4.2 3.5 3.4 4.1 4.9 5.9 6.3 6.5 6.4 5.0 (excluding alcohol) % 6.3 5.5 5.4 6.6 8.0 9.4 10.1 10.7 10.8 8.0 Depressants 2 n 45 57 50 68 63 44 66 77 36 506 % 0.4 0.5 0.4 0.5 0.5 0.3 0.5 0.5 0.5 0.5 (excluding alcohol) % 0.6 0.7 0.6 0.8 0.7 0.5 0.8 0.9 0.9 0.7 Other /Stimulants n 21 34 17 29 22 31 32 33 8 227 % 0.2 0.3 0.1 0.2 0.2 0.2 0.2 0.2 0.1 0.2 (excluding alcohol) % 0.3 0.4 0.2 0.3 0.3 0.4 0.4 0.4 0.2 0.3 Hallucinogens 3 n 17 25 18 18 15 9 22 34 17 175 % 0.2 0.2 0.1 0.1 0.1 0.1 0.2 0.2 0.3 0.2 (excluding alcohol) % 0.2 0.3 0.2 0.2 0.2 0.1 0.3 0.4 0.4 0.3 Club Drugs 4 n 24 24 42 53 43 63 80 72 39 440 % 0.2 0.2 0.3 0.4 0.3 0.5 0.6 0.5 0.6 0.4 (excluding alcohol) % 0.3 0.3 0.5 0.6 0.5 0.8 1.0 0.9 1.0 0.6 Other 5 n 41 39 82 97 152 121 208 197 74 1,011 % 0.4 0.3 0.7 0.7 1.1 0.9 1.6 1.4 1.1 0.9 (excluding alcohol) % 0.6 0.5 1.0 1.1 1.8 1.5 2. 2.3 1.9 1.5 Total N 10,863 12,305 12,443 13,767 13,837 13,308 13,306 14,274 6,555 110,658 (excluding 8 N 7,284 7,890 7,995 8,679 8,571 8,334 8,228 8,643 3,864 69,498 alcohol) 1 Includes non-prescription methadone and other opiates and synthetic opiates. 2 Includes barbiturates, benzodiazepine tranquilizers, clonazepam, and other sedatives. 3 Includes LSD, PCP and other hallucinogens. 4 Includes Rohypnol, ketamine (Special K), GHB, and MDMA (ecstasy). 5 Includes inhalants, over-the-counter and other drugs not specified. SOURCE: Drug/Alcohol Coordinated Data System, Division of Behavioral Health, Colorado Department of Human Services 36

Exhibit 15a: Numbers and Percentages of Treatment Admissions by Primary Drug Type in Colorado: 2004-12 Drug 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Alcohol n 9,842 10,165 11,529 11,293 12,803 13,259 12,678 12,623 13,620 107,812 6 % 40.6 38.7 40.8 39.5 40.7 42.1 41.7 41.3 41.7 40.8 Marijuana n 5,303 5,568 5,671 6,016 6,798 6,869 6,690 6,314 6,247 55,476 % 21.9 21.2 20.1 21.0 21.6 21.8 22.0 20.6 19.1 21.0 (excluding alcohol) % 36.8 34.6 33.9 34.8 36.4 37.6 37.8 35.2 32.8 35.5 Methamphetamine n 3,843 5,087 5,071 5,115 4,945 4,550 4,438 4,348 4,842 42,239 % 15.8 19.4 18.0 17.9 15.7 14.4 14.6 14.2 14.8 16.0 (excluding alcohol) % 26.7 31.6 30.3 29.6 26.5 24.9 25.1 24.2 25.4 27.1 Cocaine n 3,033 2,933 3,481 3,463 3,689 3,032 2,516 2,365 2,226 26,739 % 12.5 11.2 12.3 12.1 11.7 9.6 8.3 7.7 6.8 10.1 (excluding alcohol) % 21.1 18.2 20.8 20.0 19.8 16.6 14.2 13.2 11.7 17.1 Heroin n 1,282 1,445 1,299 1,280 1,435 1,709 1,778 2,200 2,642 15,070 % 5.3 5.5 4.6 4.5 4.6 5.4 5.9 7.2 8.1 5.7 (excluding alcohol) % 8.9 9.0 7.8 7.4 7.7 9.4 10.0 12.2 13.9 9.7 Other Opioids 1` n 621 735 849 1,004 1,278 1,563 1,754 1,931 2,306 12,041 % 2.6 2.8 3.0 3.5 4.1 5.0 5.8 6.3 7.1 4.6 (excluding alcohol) % 4.3 4.6 5.1 5.8 6.8 8.6 9.9 10.8 12.1 7.7 Depressants 2 N 99 98 123 130 154 155 123 144 177 1,203 % 0.4 0.4 0.4 0.5 0.5 0.5 0.4 0.5 0.5 0.5 (excluding alcohol) % 0.7 0.6 0.7 0.8 0.8 0.8 0.7 0.8 0.9 0.8 Other /Stimulants n 57 57 52 38 60 49 57 73 66 509 % 0.2 0.2 0.2 0.1 0.2 0.2 0.2 0.2 0.2 0.2 (excluding alcohol) % 0.4 0.4 0.3 0.2 0.3 0.3 0.3 0.4 0.3 0.3 Hallucinogens 3 n 27 33 35 33 41 36 28 50 60 343 % 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.2 0.1 (excluding alcohol) % 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.3 0.3 0.2 Club Drugs 4 n 55 49 48 63 79 79 113 180 142 808 % 0.2 0.2 0.2 0.2 0.3 0.3 0.4 0.6 0.4 0.3 (excluding alcohol) % 0.4 0.3 0.3 0.4 0.4 0.4 0.6 1.0 0.7 0.5 Other 5 n 88 92 91 155 196 211 198 357 330 1,718 % 0.4 0.4 0.3 0.5 0.6 0.7 0.7 1.2 1.0 0.7 (excluding alcohol) % 0.6 0.6 0.5 0.9 1.0 1.2 1.1 2.0 1.7 1.1 Total N 24,251 26,262 28,249 28,590 31,512 31,512 30,373 30,585 32,658 263,958 (excluding alcohol) N 14,400 16,097 16,720 17,297 18,675 18,253 17,695 17,962 19,038 156,146 1 Includes non-prescription methadone and other opiates and synthetic opiates. 2 Includes barbiturates, benzodiazepine tranquilizers, clonazepam, and other sedatives. 3 Includes LSD, PCP and other hallucinogens. 4 Includes Rohypnol, ketamine (Special K), GHB, and MDMA (ecstasy). 5 Includes inhalants, over-the-counter and other drugs not specified. SOURCE: Drug/Alcohol Coordinated Data System, Division of Behavioral Health, Colorado Department of Human Services 37

Exhibit 16: Demographic Characteristics of Clients Admitted to Treatment in the Denver metro area-- Percents: CY 2004 compared to CY 2013 (1 st half) Alcohol Cocaine Heroin Methamphet. Rx Opioids Marijuana Year 2005 2013 2005 2013 2005 2013 2005 2013 2005 2013 2005 2013 Total N by Year 3579 2691 1462 465 1029 831 1494 787 457 418 2694 1189 Gender Male 70.1 67.8 59.4 57.0 66.2 63.5 56.4 61.0 49.9 48.1 77.9 80.4 Female 29.9 32.2 40.6 43.0 33.8 36.5 43.6 39.0 50.1 51.9 22.1 19.6 Race/Ethnicity White 65.2 60.5 40.2 35.1 61.3 76.7 81.9 76.6 85.3 77.0 41.6 43.1 African- American 7.3 9.3 25.3 31.2 9.4 4.2 1.7 2.5 3.5 3.6 21.4 20.2 Hispanic 21.8 25.5 31.1 30.3 25.9 15.2 13.3 17.2 7.7 17.9 32.2 32.8 Other 5.7 4.7 3.4 3.4 3.4 3.9 3.1 3.7 3.5 1.5 5.8 3.9 Age at Admission Under 18 5.1 1.5 2.9 0.9 0.4 2.5 4.3 1.8 1.3 1.7 42.2 27.8 18 to 24 16.4 14.7 14.0 8.8 11.7 33.7 24.4 10.8 11.4 17.0 27.0 25.6 25 to 34 25.8 34.5 29.2 26.7 28.6 34.7 38.9 43.8 29.3 43.8 18.4 28.7 35-44 29.3 23.3 37.4 28.8 24.8 16.8 24.3 27.3 24.9 24.2 9.2 11.2 45-54 18.0 18.1 14.2 28.2 25.7 7.2 7.8 14.6 25.8 7.9 2.7 5.2 55 and older 5.4 7.9 2.3 6.7 8.9 5.1 0.3 1.7 7.2 5.5 0.4 1.6 Route of Ingestion Smoking 0.4 0.3 62.3 59.1 9.6 21.7 58.6 60.7 0.7 6.2 92.2 92.3 Inhaling 4.9 0.6 31.9 32.7 5.7 5.2 15.1 6.7 7.2 9.1 6.1 5.6 Injecting 0.1 0.1 4.3 4.5 83.2 70.3 22.4 29.6 6.6 7.9 0.1 0.1 Oral/Other 94.6 99.0 1.5 3.7 1.5 2.8 3.9 3.0 85.5 76.8 1.6 2.0 Secondary Substance Alcohol 0 0 34.8 26.5 4.3 8.6 20.5 21.4 10.1 13.7 40.9 36.0 Cocaine 14.8 8.6 0 0 33.6 18.8 13.4 7.9 6.3 4.8 10.9 8.2 Heroin 0.5 0.6 1.5 2.5 0 0 0.9 4.5 6.1 6.8 0.3 2.2 Methamphetamin e 3.7 2.7 5.8 7.4 4.4 6.2 0 0 1.1 6.8 8.4 8.2 Marijuana 24.5 28.0 24.5 20.4 6.4 16.8 30.1 28.9 5.9 15.8 0 0 Rx Opiates 1.1 2.1 0.7 1.9 5.6 18.8 0.6 3.8 1.3 2.1 0.3 1.5 Hallucinogens 0.3 0.2 0.9 1.2 0.1 1.3 1.2 1.5 0.2 0 1.0 2.3 Sedatives 0.8 1.3 0.5 0.6 2.0 2.7 0.5 0 6.7 15.8 0.4 0.4 Other 0.6 5.3 0.6 4.9 0.3 5.6 0.9 5.7 1.1 4.7 1.2 4.7 None 53.7 51.2 30.7 34.6 43.3 21.2 31.9 26.3 61.2 29.5 36.6 36.5 SOURCE: Drug/Alcohol Coordinated Data System, Alcohol and Drug Abuse Division, Colorado Department of Human Services 38

Exhibit 17: Number and Rates of Denver Metro Drug-Related Hospital Discharge Reports per 100,000 Population for Selected Drugs (unduplicated): 2007 2012 Number and Rate per 100k 2007 2008 2009 2010 2011 2012 Alcohol N 14,465 16,005 16,130 17,515 18,264 18,144 Alcohol Rate 538.87 586.01 580.92 622.77 638.24 623.13 Marijuana N 2,091 2,438 2,507 3,397 3,526 3,558 Marijuana Rate 77.9 89.26 90.29 120.79 123.22 122.19 Cocaine N 2,583 2,334 2,135 2,252 2,231 1,901 Cocaine Rate 96.22 85.46 76.89 80.07 77.96 65.29 Heroin N 26 37 58 33 59 64 Heroin Rate 0.97 1.35 2.09 1.17 2.06 2.2 Rx Opioid N 2,301 2,618 2,851 3,441 4,257 4,098 Rx Opioid Rate 85.72 95.86 102.68 122.35 148.76 140.74 Stimulant N 836 712 786 1,021 969 1,077 Stimulant Rate 31.14 26.07 28.31 36.3 33.86 36.99 Population 2,684,335 2,731,197 2,776,620 2,812,417 2,861,627 2,911,749 SOURCE: Colorado Department of Public Health and Environment, Colorado Hospital Association Discharge Data Program Database Exhibit 18. Denver Area and US NFLIS Samples: Top 10 Most Frequently Identified Drugs of Total Analyzed Drug Items: 2013 (first half) Drug Denver Area Colorado Total US N % N % N % Cocaine 1,192 25.1 1,476 22.2 99,371 14.9 Methamphetamine 1,036 21.8 1,763 26.6 94,947 14.2 Heroin 730 15.4 820 12.4 66,181 9.9 Marijuana/Cannabis 686 14.4 1,015 15.3 213,296 32.0 XLR-11-synthetic cannabinoid 135 2.8 136 2.0 10,467 1.6 Oxycodone 91 1.9 167 2.5 21,343 3.2 Alprazolam 46 1.0 75 1.1 15,336 2.3 Hydrocodone 45 0.9 69 1.0 16,872 2.5 Clonazepam 32 0.7 * * * * Acetaminophen 31 0.7 50 0.8 8,090 1.2 Other 725 15.3 1,000 15.1 115,451 17.3 Buprenorphine * * * * 5,071 0.8 Total 4,749 100 6,639 100 666,425 100 Source: National Forensic Lab Information System Note: Denver Area in this comparison includes Denver, Jefferson and Arapahoe Counties * Not among the top ten 39

Number of Arrests Exhibit 19: Denver Adult and Juvenile Marijuana Arrests (sale and possession): 2001 to 2012 3500 3000 2500 2000 3016 2396 2789 2198 2506 1952 2110 2440 1910 2836 2309 3212 2617 2670 2251 3090 2693 2416 2110 1659 1545 1608 1500 1167 1229 1000 500 620 591 554 451 530 527 595 419 397 306 378 379 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Adult Marijuana Arrests Total Juvenile Marijuana Arrests Total All Marijuana Arrests Source: Denver Safety Office of Policy Analysis 40

Exhibit 20: Most Common Drugs in Denver Drug Related Decedents: Percent of All Cases 2004-2012 2004 2005 2006 2007 2008 2009 2010 2011 2012 Drug Contributing n % n % n % n % n % n % n % n % n % to Cause of Death Cocaine 58 38.4 82 48.2 85 50.3 75 39.7 60 28.3 53 25.6 41 27 55 28.9 25 17.0 Morphine 57 37.7 60 35.3 64 37.9 43 22.8 48 22.6 26 12.6 18 11.8 20 10.5 12 8.2 Alcohol 60 39.7 44 25.9 65 38.5 66 34.9 75 35.4 72 34.8 52 34.2 56 29.5 39 26.5 Codeine 25 16.6 36 21.2 36 21.3 18 9.5 19 9.0 11 5.3 3 2.0 5 2.6 1 0.7 Heroin 6 4.0 18 10.6 17 10.1 18 9.5 27 12.7 49 23.7 35 23.0 49 25.8 41 27.9 Methadone 13 8.6 17 10.0 16 9.5 14 7.4 15 7.1 15 7.2 11 7.2 19 10.0 12 8.2 Oxycodone 6 4.0 12 7.1 7 4.1 38 20.1 33 15.6 48 23.2 24 15.8 36 18.9 34 23.1 Methamphetamine 7 4.6 12 7.1 9 5.3 12 6.3 15 7.1 10 4.8 14 9.2 20 10.5 12 8.2 Acetaminophen 9 6.0 11 6.5 2 1.2 14 7.4 13 6.1 4 1.9 8 5.3 6 3.2 6 4.1 Diazepam 11 7.3 10 5.9 11 6.5 19 10.1 16 7.5 23 11.1 19 12.5 25 13.2 18 12.2 Alprazolam 3 2.0 10 5.9 5 3.0 13 6.9 15 7.1 20 9.7 12 7.9 20 10.5 16 10.9 Hydrocodone 4 2.6 7 4.1 10 5.9 8 4.2 22 10.4 18 8.7 10 6.6 14 7.4 13 8.8 Dihpenhydramine 2 1.3 7 4.1 1 0.6 11 5.8 11 5.2 3 1.4 9 5.9 11 5.8 10 6.8 Clonazepam 0 0 2 1.2 0 0 1.5 4 1.9 8 3.9 7 4.6 11 5.8 8 5.4 Fentanyl 2 1.3 3 1.8 3 1.8 5 2.6 5 2.4 13 6.3 5 3.3 9 4.7 7 4.8 Decedents* 151 170 169 189 212 207 152 190 147 Source: Denver Medical Examiner s Office Autopsy Reports *Drug totals won t sum to decedents because more than one drug may be found in individual s toxicology Exhibit 21: Most Common Combinations of Drugs in Decedents by Percent of All Cases: 2005 to 2012 Combinations 2005 2006 2007 2008 2009 2010 2011 2012 n % n % n % n % n % n % n % n % Alcohol and any 39 22.9% 57 33.7% 50 26.5% 57 26.9% 60 29.0% 39 25.7% 46 24.2% 32 21.2% other drug Cocaine and 16 9.4% 26 15.4% 22 11.6% 15 7.1% 17 8.2% 8 5.3% 17 8.9% 7 4.8% Alcohol Cocaine and 8 4.7% 9 5.3% 5 2.6% 8 3.8% 14 6.8% 15 9.9% 21 11.1% 10 6.8% Heroin Cocaine and any 50 29.4% 61 36.1% 40 21.2% 36 17% 35 16.9% 28 18.4% 44 23.2% 19 12.9% other drug Oxycodone & any 0 0.0% 1 0.6% 19 10.1% 29 13.7% 42 20.3% 21 13.8% 34 17.9% 31 21.1% other drug Opiates ( inc. 20 11.8% 12 7.1% 26 13.8% 24 11.3% 37 17.9% 18 11.8% 38 20% 32 21.8% heroin) and benzodiazepines Total Decedents 170 169 189 212 207 152 190 147 Source: Denver Medical Examiner s Office Autopsy Reports Exhibit 22: Number of Statewide Drug-Related Calls to the Rocky Mountain Poison and Drug Center: 2004 to 2013 (human exposure calls only) Drug 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Alcohol 762 884 868 858 916 840 913 991 951 912 Cocaine/Crack 120 107 129 91 104 63 64 96 64 80 Heroin/Morphine 20 24 25 21 23 29 19 47 50 44 Marijuana 68 78 45 70 61 54 107 98 130 136 Methamphetamine 95 127 29 31 51 60 72 78 72 117 Club Drugs 43 49 47 49 55 46 48 53 51 33 Note: Club Drugs includes Gamma Hydroxybutyrate and MDMA 41

Number of Exhibits Exhibit 23: Other Opiate Exhibits (Excluding Heroin): Denver Crime Lab 2001 through 2013 250 226 200 183 202 211 R² = 0.7655 150 132 154 143 131 162 100 92 103 50 46 47 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: Denver Crime Lab 42

Percent 60.0% Exhibit 24: Opioid Exhibits Analyzed in the Denver Crime Lab: By Percent of Total Opiate Exhibits: 2001 through 2013 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Oycodone Hydrocodone Morphine Buprenorphine Methadone Hydromorphone Source: Denver Crime Lab 43

Number of Prescriptions Dispensed Rate per 1000 50000 45000 40000 35000 Exhibit 25: Oxycodone Prescriptions Dispensed in Denver and Rate per 1000 Population: 1st Quarter 2008 through Fourth Quarter 2013 431364313343332 375003806938222 39843406334034941969 38396 39252 38892 41020 41402 40801 4024340205 31575 333923363635322 34408 35160 100.00 90.00 80.00 70.00 30000 25000 20000 15000 10000 5000 0 54.42 57.45 57.77 60.56 58.90 60.08 63.97 64.83 64.98 67.62 68.85 68.25 70.87 72.72 72.59 72.80 64.40 65.72 65.01 68.41 68.93 67.81 66.77 66.59 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Oxycodone Prescriptions Dispensed Oxycodone Rate per 1000 Source: Prescription Drug Monitoring Program 44

Number of Prescriptions Dispensed Rate per 1,000 Population Exhibit 26. Hydrocodone Prescriptions Dispensed in Denver and Rate per 1000 Population: 1st Quarter 2008 through 4th Quarter 2013 120.00 55000 45000 45826 45474 45492 45671 45671 46601 48039 48723 47353 46999 46084 45627 45645 46203 44173 44652 44103 44523 45128 44461 44913 42753 42755 41675 100.00 80.00 76.14 78.85 76.69 77.97 77.87 75.36 77.91 77.78 79.23 78.22 77.31 75.31 81.12 79.83 76.82 75.82 81.72 78.69 74.32 77.05 74.77 35000 71.06 70.94 69.03 60.00 25000 40.00 15000 20.00 5000 0.00 Hydrocodone Prescriptions Dispensed Hydrocodone Rate per 1000 45

Number of Exhibits Source: Colorado Prescription Drug Monitoring Program 160 Exhibit 27: Benzodiazepine Exhibits: Denver Crime Lab 2001 through 2013 140 140 120 100 80 74 73 84 79 84 R² = 0.6213 60 59 48 46 53 49 62 40 37 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 46

Number of Exhibits 60.0% Exhibit 28: Selected Benzodiazepine Exhbits Analyzed in Denver Crime Lab: By Percent of Total Benzodiazepine Exhibits: 2001 through 2013 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Alprazolam Clonazepam Diazepam Lorazepam Source: Denver Crime Lab Exhibit 29: MDMA vs. MDMA Substitute Exhibits Analyzed in Denver Crime Lab: 2001 through 2013 200 192 180 173 160 153 156 140 120 100 112 110 103 92 114 94 101 106 117 80 67 75 74 74 60 57 51 45 45 47 40 20 33 28 22 22 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 MDMA and Substitutes MDMA 47

Rate per 1000 Source: PDMP 30.00 Exhibit 30: Selected Denver Benzodiazepine Rx Dispensed Rate per 1000: 1st Qtr 2008-4th Qtr 2013 25.00 20.00 15.00 20.41 21.22 21.60 22.09 22.02 22.18 22.61 22.72 23.07 22.16 21.55 21.03 20.03 20.29 20.24 20.86 20.83 20.37 18.89 18.84 18.77 18.17 18.13 17.53 23.80 23.82 23.37 22.56 23.95 24.05 23.66 23.42 23.40 22.75 22.96 23.26 22.00 22.62 22.17 21.89 22.55 22.69 22.06 23.48 23.13 22.40 22.96 23.48 10.00 10.94 11.47 11.41 11.68 11.44 11.52 12.02 12.28 12.44 12.74 12.89 12.81 13.35 13.58 12.89 12.94 13.53 13.34 12.68 13.26 13.30 12.98 13.15 13.43 5.00 0.00 1st Qtr- 08 2nd Qtr- 3rd-Qtr- 4th Qtr- 08 08 08 1st Qtr- 09 2nd Qtr- 3rd Qtr- 4th Qtr- 09 09 09 1st Otr- 10 2nd Qtr- 3rd Qtr- 4th Qtr- 10 10 10 1st Qtr- 11 2nd Qtr- 3rd Qtr- 4th Qtr- 11 11 11 1st Qtr- 12 2nd Qtr- 3rd Qtr- 4th Qtr- 12 12 12 1st Qtr- 13 2nd Qtr- 3rd Qtr- 4th Qtr- 13 13 2013 Alprazolam Rate per 1000 Lorazepam Rate per 1000 Diazepam Rate per 1000 48

Data Sources Alcohol and selected drug prevalence data for Denver, Colorado, and the US are provided from the following sources: 1) the National Survey on Drug Use and Health (NSDUH), 2) the Behavioral Risk Factor Surveillance System (BRFSS), 3) the Healthy Kids Colorado Survey (HKCS) and 4) the Youth Risk Behavior Survey (YRBS). The NSDUH is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The survey is the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, non-institutionalized population of the United States aged 12 years or older. The survey interviews approximately 67,500 persons each year. Data are available at the state and sub-state levels. The Colorado BRFSS is a system of telephone surveys sponsored by the Centers for Disease Control (CDC) to monitor lifestyles and behaviors related to the leading causes of mortality and morbidity. In recent years, health professionals and the public have become increasingly aware of the role of such lifestyle factors as binge drinking, cigarette smoking, excess weight, a sedentary lifestyle, and the nonuse of seat belts in contributing to injury, illness and death. In 1981, the CDC began using the BRFSS as a method of estimating the prevalence of high risk behaviors and lifestyle factors that contribute to death and disease. Colorado participated in this project with point-in-time surveys in 1982 and 1987. The Survey Research Unit of the Health Statistics Section of the Colorado Department of Public Health and Environment (CDPHE) began collecting data on a monthly basis in January 1990. The Survey Research Unit now completes over 300 BRFSS surveys a month with adult residents of Colorado (i.e., 18 and over). The HKCS was developed to monitor statewide and local trends for school-attending youth by surveying a representative sample of middle and high school students. The HKCS integrates items from the CDC s Youth Risk Behavioral Survey (YRBS), the Colorado Youth Survey (CYS), and additional items selected by Colorado state agencies. The HKCS contains a total of 142 items on the high school version and 127 items on the middle school version. The HKCS provides information on a wide range of youth attitudes and behaviors including substance use, violence and delinquency, mental health, and academic performance. The HKCS data used in this report is from the first administration of the survey in the Denver Public Schools among a representative sample of 6 th, 8 th, 9 th, and 11 th graders during the spring and fall of 2008; and the second administration in DPS among 6 th through 12 th graders in the 2011-12 school year. The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-risk behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of obesity and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and local school-based 49

YRBSs conducted by state and local education and health agencies. This report summarizes results from the 2011 national survey. Treatment data are provided by the Drug/Alcohol Coordinated Data System (DACODS) which is maintained by the Office of Behavioral Health (OBH) at the Colorado Department of Human Services. Data for this system are collected on clients at admission and discharge from all Colorado alcohol and drug treatment agencies licensed by OBH. Treatment admissions are reported by the primary drug of use (as reported by the client at admission) unless otherwise specified. Annual figures are given for calendar years (CY) 2004 through CY 2013 (1 st half) Drug-related emergency department (ED) reports were provided for Denver County, Denver Metro and Colorado by Colorado Department of Health and Environment from CY 2012 through CY 2012. Alcohol and drug-related mortality data for the City and County of Denver for CY 2003 through CY 2012 are from the Denver Office of the Medical Examiner. Drugs associated with mortality are based on blood toxicology performed as part of the autopsy. The toxicology findings are part of the autopsy report. Drug-related mortality data for Denver County, Denver Metro and Colorado for CY 2007 through 2012 are from the Colorado Department of Public Health and Environment. Deaths are based on ICD-10 codes. Hospital discharge data for the Denver metro area for CY 2007through CY 2012 for Denver County, Denver Metro and Colorado were provided by the Colorado Department of Health and Environment based on diagnoses (ICD-9-CM codes) for inpatient clients at discharge from all acute care hospitals and some rehabilitation and psychiatric hospitals. These data exclude ED care. Rocky Mountain Poison and Drug Center (RMPDC) data are presented for Colorado. The data represent the number of calls (human exposure only) to the center regarding "street drugs" from 2004 through 2013 National Forensic Lab Information System (NFLIS) data are presented for Denver, Jefferson, and Arapahoe Counties for the first half of 2013 with a comparison to Colorado and to the entire US. The NFLIS is a Drug Enforcement Administration program through their Office of Diversion Control that systematically collects drug identification results and associated information from drug cases analyzed by federal, state and local forensic laboratories. Additional drug specific crime lab statistics for 2001 through the first half of 2013 were obtained from the Denver Crime Lab, Denver Police Department. Denver Adult and Juvenile Arrest data from 2001 through 2012 were obtained from the Denver Safety Office of Policy Analysis. 50

Statistics on seized drug items were obtained through CY 2008 from Colorado Fact Sheet Reports published by the Drug Enforcement Administration (DEA) Statistics on prescriptions filled for Denver residents by drug type from the 3 rd quarter 2007 through the 2nd quarter 2013 were obtained from the Colorado Prescription Drug Monitoring Program (PDMP), Colorado Department of Regulatory Agencies, Division of Registrations, Board of Pharmacy. Data on tests for driving under the influence of drugs from 2009 through 2012 are from the Colorado Department of Public Health and Environment, Laboratory Services Division. Data on the number of medical marijuana applications and approved patients from December 2009 through February 2013 is from the Colorado Department of Public Health and Environment, Medical Marijuana Registry. Intelligence data (including price and availability) were obtained from the Denver Epidemiology Work Group including clinicians, outreach workers, researchers, medical examiner s office staff, public health, and regional and local law enforcement officials. Colorado and Denver Populations Census data from the Colorado Division of Local Government website place the 2010 Colorado population at 5,029,196, and the 2010 City and County of Denver population at 600,158. For Colorado 12, 50.4 percent are male and 49.6 percent are female; 70 percent are White (excluding White Hispanics); 4.0 percent are Black; 1.1 percent are American Indian/Alaskan Native; 2.8 percent are Asian; and.1 percent are Native Hawaiian/Pacific Islander. Of the total Colorado population, 20.7 percent are Hispanic of any race. For Denver, 52.2 percent are White (excluding White-Hispanic or Latino), 10.2 percent are Black, 1.4 percent are American Indian/Alaska Native, 3.4 percent are Asian/Pacific Islander, and 31.8 percent are Hispanic (of any race) 1 ; 50.6 percent are male and 49.4 percent are female; 23.9 percent are under 20, 18.9 percent are 20 to 29, 17.7 percent are 30 to 39; and 12.9 percent are 40 to 49, 11.6 percent are 50 to 59, 7.8 percent are 60 to 69 and 7.2 percent are 70 and over 1. 12 2010 Census 51

Syringe Access Programming Results at HRAC (February 8 2012-March 31 2014) ~1,800+ unique clients to date! (1,725 with complete data)= largest SAP in CO 10,100+ (10,073) syringe access episodes Average number of people represented per exchange: 2.7 698 in February ( abridged month); 751 in March ~14,000+ visits to the drop-in (13,939) Outreach numbers: 1,785 contacts (~ ½ IDUs) Community syringe clean up: 5,200+ dirties 4,483 referrals Overdose prevention: 248 trained, 83 lives saved 52

Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 HRAC Syringes distributed vs. disposed 30000 25000 20000 15000 Feb 2012 Mar 2014 439,119 clean syringes distributed 277,900 dirty syringes safely disposed ~30,219 Hit Kits distributed IN OUT 10000 Exemption cards become available 5000 0 HRAC Syringe access programming trends Feb 2012- Mar 2014 3000 2500 2000 New Total Number of Exchanges Total enrollees 1500 PPL Rep 1000 500 0 53

Averages one year later.. Results Feb-March 2013 vs. Feb-Mar 2014 Average Average number Feb- number Feb- Mar 2013 Mar 2014 New enrollees per month 66 vs. 67* Total Number of Exchange episodes 588 vs. 725 Syringes in 11,829 vs. 16,147 Syringes out 19,789 vs. 22,942 PPL Rep through secondary 1,491 vs. 1,498 exchange AVG PPL represented 2.5 vs. 2.2 HRAC IDU drug use behavior Drugs injected most past 30 days (n=1,725) {2.2} = Smoke crack? yes Smoke crack? no the percentage of clients that inject steroids. Heroin alone 38% Multiple drugs 26% Methamphetamine 18% Speedball (heroin & cocaine) 9% Goofball 4% Cocaine or other 5% Only 30% of participants surveyed had smoked crack in the past year 80% of them have shared a crack pipe in the past 30 days 54

Age at intake HRAC IDU Client demographics 600 500 400 73.0% Male 300 200 100 0 Age at intake 45+ 35-44 25-34 18-24 0 100 200 300 Temporary Temporary 36% 34% Homeless 49% Housed 14% 17% HRAC IDU s in Denver (N=1,725) Percentage of clients whose first time is at an SAP: 88.7% How did you hear about us? 76% said word of mouth, followed by referrals (8%) and outreach (6%) 10.4% of clients are in the sex trade Close to 100% of our clients HAVE been in treatment multiple times before (not including AA/NA) 55.8% have no healthcare payment program; 44.2% do. 14% have CICP, 15% have Medicaid, and 8% have Private insurance 55

What age did you start injecting? 350 300 250 200 150 68% UNDER age 25 100 50 0 <18 18-24 25-34 Average age of initiation: 24 35-44 45+ 80% OVER age 25 { 90% } the percentage of clients that had never been to a syringe exchange before HRAC being the first time accessing clean syringes and safe disposal. Average age of intake: 36 350 300 250 200 150 100 50 0 Age at time of HRAC intake <18 18-24 25-34 35-44 45+ HCV & HIV status at intake (n=1,725) 27.3% Positive 12.8% Don t know 59.9% Negative Hepatitis C status Positive Negative Unknown/indeterminant Est. 73% Denver IDU are HCV+ or show antibodies* HIV status HRAC on-demand, on-site HIV tests (223) HCV tests (200) & STI tests (67) Denver averages nearly 21% HIV+ and nearly 19% living with AIDS report being infected from syringe sharing* Positive Negative Unknown/indeterminant 2.9% Positive 9.7% Don t know 87.4% Negative *Source: Denver Public Health, NHBS, 2009 56

HRAC Syringe access impact (n=100) How many times per day do you inject? Mean: 3.4 times per day Median: 3 times per day Range: >1-16 times per day How many times have you lent out works in the past 30 days? Before coming to HRAC: 6.2 times After 3-months (follow-up) at HRAC: 4.1 times How many times have you borrowed works in the past 30 days? Before coming to HRAC: 3.6 times At follow-up: 1.1 times Median = 0.5 (72% said never ) How many times do you re-use a syringe? Intake Mean: 6.9 Follow-up Mean: 1.3 Average IDU injects minimum 1,000 times per year (CDC, 2007) Mapping and geocode analysis Data source: http://data.denvergov.org/dataset/city-and-county-of-denvercrime. In the first 12 months (Feb 2012- Feb 2013) after HRAC began operation at 733 Santa Fe Drive, less crime in general has occurred within a 4-block radius than in the 12 months preceding HRACs arrival. 650 pre-hrac vs. 514 post-hrac crimes Heroin related crimes in the Arts District since HRAC moved to 733 Santa Fe Dr. have virtually disappeared within a 4-block radius of HRAC, vs. 7 the year before. Throughout Denver (outside the 4-block radius of HRAC) there were 251 heroin possession arrests, compared to 132 the year before. Even with an increase in heroin possession throughout the city in the same time period, within 4-blocks of HRAC the occurrence has decreased to zero. *Crime analysis verified through: http://www.denvergov.org/police/policedepartment/crimeinformation/crimemap/tabid/443033 /Default.aspx 57

From our clients. Thank you for caring about the people at the bottom. To know that someone cares enough to help and assist during hard time and difficult situations to overcome. Thanks for all you do for us. I no longer share needles or need to use old, use syringes. I feel cleaner and safer knowing my chances of being exposed to HIV are drastically reduced. Well, I don't have to worry about sharing needles in the past if that all you had then that s what you did. My arms are no longer infected; I'm always using clean needles, or I have to clean them one time to reuse them and 1 more time. Sometimes I can come in right away to exchange them. It has helped 100% for my arms and the infections have stopped. They have been here on the days I would have jumped in front of a bus but HRAC talked me into taking a leap of faith and patience instead. Yes, I don't feel so alone and helpless. I realize that the disease, addiction, is able to be beat and life is always worth living and this can be a positive phase in my life. When I gain control of my life I want to help people like me and the homeless. When complete strangers treat you like family it heals you. And knowledge has saved me from death and suicide. I'm a lot more knowledgeable about my use, I'm cleaner and more sterile when using. I eat more! I am no longer living on the streets, moved in with my dad and I am starting on methadone. Thank you for all your hard work and dedication! It means a lot to know that there are people out here who care! I'd like to express the gratitude to all the staff members here day after day with smiles and cheer to each person who walked through the door! I don't have a clue how ya'll do it, but you do! I always feel welcome safe and respected, thank you! 58

DEWG Click Teen to edit Survey Master title style Presentation Click to edit Master subtitle style April 18, 2014 Mission Rise Above Colorado is a drug abuse prevention organization that measurably impacts teen perceptions and attitudes about the risks of substance abuse to help youth make empowered, healthy choices. 2 59

Key Objectives Through information and materials developed with a teen s point of view, Rise Above Colorado helps teens learn about drug abuse so they can make empowered, positive, smart choices to lead the healthy life they deserve. Rise Above Colorado provides proactive, youth-focused outreach and education programs about drug abuse that shape teens attitudes and perceptions, subsequently changing drug use patterns. Rise Above Colorado s community outreach campaign creates a forum for parents and families to effectively connect with and inform teens about the impacts of drug abuse, the healthy alternatives to drug use and the effective refusal skills they can successfully practice. 3 60

Colorado Teenage Drug Use & Attitude Assessment - HealthCare Research Surveyed 614 Colorado teenagers by telephone, after obtaining the consent of their parents 12-17 years of age/grades 7-12 Quotas were set by county and then weighted back to population estimates. Data collection occurred between September 16 th and October 27 th, 2013. The survey covered material from past assessments (2009, 2010, and 2011), along with new areas of interest. Questionnaire took 17 minutes on average to complete Subject areas included: Attitudes Knowledge and behavioral: awareness, interest, access and usage Communications awareness Demographics The maximum margin of sampling error is +/- 3.9 points on a sample size of 614 interviews 5 Survey Methodology- Geography Metro Area: n=274 Front Range: n=140 Mountains/ West n=100 South East n=50 South n=50 6 61

Teen Survey Segments 7 2009/2013 Risk Perception Shifts How much risk, if any, do you think there is involved in each of the following activities? Using Once or Twice Meth Heroin 2013 2011 2010 2009 2013 2011 2010 2009 Great Risk 90% 79% 88% 88% 86% 78% 84% 88% Moderate Risk 5% 95% 6% 94% 6% 94% 11% 90% 8% 92% 7% 95% 10% 94% 14% 92% Comparing perceived risk to prior survey periods (2009, 2011 and 2012) shows that the perceived risk of limited use of meth increased significantly from 2009 to 2010, and has held at this higher level, currently at 90%. Marijuana 2013 2011 2010 2009 44% 47% 49% 48% 30% 22% 20% 24% 74% 69% 69% 72% 0% 20% 40% 60% 80% 100% Regular Use Heroin Meth Marijuana 2013 2011 2010 2009 2013 2011 2010 2009 2013 2011 2010 2009 Great Risk 92% 95% 90% 95% 94% 93% 95% 90% 40% 65% 71% 25% 69% Moderate Risk 1% 96% 2% 94% 2% 97% 3% 93% 2% 2% 3% 1% 15% 86% 17% 82% 65% 14% 83% 96% 95% 96% 93% 0% 20% 40% 60% 80% 100% Base: 2013: Those aware of each drug; varies by drug, Prior years: All Participants n=~600 Arrows indicate statistically significant differences from prior years at the 95% level of confidence. 8 62

Limited-Use Risk (Once or Twice) How much risk, if any, do you think there is involved in each of the following activities? Top-Box Ratings (% Great Risk ) Gender Age Parent Marital Status Overall Female Male 12 13 14 15 16 17 Married Divorced Other Meth 90% 91% 88% 90% 85% 85% 87% 94% 92% 91% 83% 68% Heroin 86% 82% 89% 84% 82% 81% 86% 88% 90% 87% 78% 75% Prescription Drugs 64% 66% 62% 79% 71% 62% 68% 62% 57% 65% 57% 52% Prescription Stimulants 60% 66% 55% 60% 58% 60% 56% 62% 61% 60% 60% 60% Prescription Pain Relievers 59% 62% 55% 53% 70% 55% 51% 61% 59% 59% 57% 53% Cough Syrup 56% 55% 57% 49% 53% 53% 53% 62% 56% 56% 49% 65% Marijuana 44% 47% 41% 70% 64% 46% 35% 37% 30% 47% 26% 44% Alcohol 33% 34% 32% 39% 53% 34% 28% 27% 23% 34% 20% 48% Top-Box Ratings (% Great Risk ) Denver Metro Front Range Region Mountains/ West East South Caucasian Hispanic Ethnicity Black/ African American Asian Native American Meth 90% 87% 91% 85% 98% 92% 83% 75% 91% 74% Heroin 86% 83% 92% 84% 88% 88% 80% 93% 88% 66% Prescription Drugs 59% 64% 74% 78% 86% 63% 68% 60% 61% 55% Prescription Stimulants 57% 61% 67% 64% 71% 60% 66% 73% 44% 51% Prescription Pain Relievers 59% 54% 57% 72% 75% 58% 57% 53% 78% 65% Cough Syrup 53% 55% 61% 68% 68% 55% 55% 60% 55% 71% Marijuana 41% 46% 44% 66% 53% 44% 43% 45% 58% 28% Alcohol 32% 34% 29% 34% 48% 31% 35% 31% 45% 35% Base: Those aware of each item; varies by subset The above tables show demographic differences in the perceived risk of limited use for each drug. Girls are significantly less likely than boys to consider limited use of heroin as being risky (82% versus 89%), but girls rate stimulants as presenting more of a risk (66% v. 55%). While perceived risk is similar across all age groups when it comes to meth, heroin, prescription drugs and cough syrup, the perceived risk of occasional use of marijuana and alcohol declines as age increases, especially for marijuana (from around 68% among 12 and 13 year-olds to less than 40% among those over 14). Other notable differences exist by marital status of parents and ethnicity, with teens whose parents are married being more likely to see greater risk in the occasional use of meth, heroin and marijuana, and Caucasians being more likely to see greater risk in the limited use of meth. Prescription drug use is considered less risky among metro area teens (59%) than those living in the southern part of the state (86%). 9 Perception of Risk by Segment 10 63

Marijuana- Ease of Access 55% Marijuana 64% 63% 50% 2009 2010 2011 2013 % Very + Somewhat Easy 11 Usage Past Month Past Year Ever Alcohol 7% 14% 11% 32% Marijuana 6% 5% 5% 16% Prescription Drugs Prescription Stimulants Prescription Pain Relievers Cough Syrup Meth 2% 5% 3% 2% 1% 0.2% Among demographic groups, reported marijuana usage is significantly higher among boys (19% compared to 12% of females), and marijuana and Rx use is significantly higher among Hispanics (23%) and teens with divorced parents (32%). 0% 10% 20% 30% 40% 12 64

Drug Usage by Segment 13 First Use How old were you when you first tried the following items? Alcohol Marijuana Prescription Drugs 9% 3% 7% 13% 14% 26% 23% 5% 10 or Younger 11 12 13 14 15 16 17 1% 2% 1% 11% 23% 34% 20% 8% 10 or Younger 11 12 13 14 15 16 17 2% 0% 0% 10% 14% 35% 34% 5% 10 or Younger 11 12 13 14 15 16 17 Cumulative Trend Teens who reported using any of these drugs were asked at what age they first tried them. Alcohol use began the earliest, with one out of ten teens (9%) who tried alcohol doing so by age 10, and nearly half (46%) by age 14. Marijuana and non-prescribed prescription drugs were initially used later, with most first experiences being at age 13, and most of those who use it having first tried it by age 16. The one self-reported meth user in the study said she first tried meth when she was 15 years old. Cough Syrup 0% 0% 23% 0% 0% 45% 32% 0% 10 or Younger 11 12 13 14 15 16 17 Base: Those who have used each item; varies by item 14 65

Marijuana- Correlation of Use & Attitudes Correlations Between Statements and Curiosity Among Users Teens Who Have Used Marijuana Now that marijuana has been legalized in Colorado, I am more likely to use it My parents would be okay if I smoked marijuana once in a while 0.35 Drugs aren t that dangerous if you don t use them too often 0.29 Parents have no idea how much pressure is on us, and drugs help us deal with all of that 0.27 Experimenting with drugs is just part of being a teenager - It s not that big a deal 0.25 0.58 0.00 0.20 0.40 0.60 0.80 1.00 15 Attitudes- Advocacy Would you give a friend a hard time if he or she were going to try the following? Meth 92% Prescription Drugs 88% Cough Syrup 88% Marijuana 72% Alcohol 67% % Responding Yes* 16 66

Attitudes- Advocacy Would you give a friend a hard time if he or she were going to try the following? Meth 92% Prescription Drugs 88% Cough Syrup 88% Marijuana 72% Alcohol 67% % Responding Yes* 16 Parental Conversations Have you ever talked to your parents about the following? Alcohol Marijuana Prescription Drugs Cough Syrup 16% 32% 70% 79% Only about two-thirds of teens under 14 years of age say they have discussed any of the drugs covered in this study with their parents. This jumps to about 80% for alcohol at the age of 14 and three-quarters for marijuana. Marijuana discussions are more likely to occur among teens living in the Denver Metro area (73%) 0% 20% 40% 60% 80% 100% 17 67